The Anatomy of a Prescription Error

It should be an easy day. It's a Thursday. Thursdays are never really that busy in this pharmacy. The big order doesn't come until tomorrow. You don't have to create an order. It's in the middle of October, and while flu shots are really starting to pick up, you haven't had enough of them to really impact your work day.

You're scheduled to be at the pharmacy at 10, so you have plenty of time to sleep in. You get up at a decent time, have a nice breakfast, and even get some exercise in before showering and getting ready for work. You're nice and relaxed, and you truly feel that this will be a good day.

When you arrive at the pharmacy and take that first step through the door, you come upon what looks like a disaster area. Labels are all over the place. There's a long line at the register. The other pharmacist is hung up on a phone call, and the lone technician is getting frustrated dealing with a customer. No, the customer is not being rude. He's simply having an insurance problem that the technician, despite working in the store for 25 years, has no idea how to solve... mostly because she's completely computer illiterate.

You see... The pharmacist scheduled to open the store that Thursday got there 10 minutes late. Therefore at 10:00, a full 2 hours after we open, all the scripts that were left on the refill line overnight still were not finished, and those labels were in no particular order all over the pharmacy counter. That one technician, despite having all that experience and being full-time, has never counted a prescription or typed a new prescription. She's basically a highly paid cashier.

Before even taking off your jacket, you walk over to the computer to help the technician. It takes you less than 30 seconds to solve the problem that had frustrated her for the last 5 minutes. Afterwards, you hang up your jacket, take a deep breath, and get to work. No time for pleasantries. No time to get settled. You jump right into the fray in an attempt to get the pharmacy to the point it should have been over an hour ago.

However, it's never as easy as just putting your head down and filling scripts. The second technician was supposed to be in at 10:00, but at 10:20, she's still not there. Therefore, you're forced to constantly jump between being a pharmacist and the world's highest paid cashier. Finally, at 10:30 the second technician strolls in. There's no explanation for the tardiness, and quite frankly, you don't have the time to listen even if there was one, so you just keep chugging along.

Just when it looks like you're starting to gain some control, the phone calls start coming. The other pharmacist (the one that showed up 10 minutes late), is the floater scheduler for the district. He has to get that floater schedule out by Thursday of every week. However, the stores for which he schedules and the floaters that work in them are such major pains in the ass that he has to constantly revise the schedule all week. Therefore, in the middle of this crazy Thursday, he has to stop for 10 to 20 minutes at a time to handle scheduling emergencies. That leaves you to work the bench alone.

The scripts keep piling up, and on this day, the customers seem to be in extra need for pharmacist attention. You do your best, but you're only one pharmacist trying to do the work of two without much help from your cashier-level technicians. Now, the other pharmacist gets called upstairs to speak to the main store manager, so he disappears for a good 20 minutes. At this point, frustration is really starting to set in.

The wait time at the pharmacy is usually no more than 20 minutes, so when dropping off scripts, the techs/clerks habitually tell the customers it will take 20 minutes for their scripts to be ready. Realizing that you're so far behind that there's no way you can fill new scripts in 20 minutes, you tell everyone that the wait time is now AT LEAST half an hour. The next technician/customer exchange goes something like this:

"The wait time is 30 minutes, but it might not actually be that long. We're just really busy, so we're just telling people 30 minutes, but it will probably be done before that, so stop back and check in a little bit."

Therefore, despite the at least 30 minute wait time, customers routinely return to the pharmacy counter in 15 to 20 minutes. Upon return, the technicians apologize to the customer that it's not ready yet, and then both the customers and technicians look at you expecting you to drop everything you're presently doing to finish their prescriptions. You don't want to, but you can't help but start rushing in this situation.

One customer wants his Suboxone prescription that he dropped off 15 minutes ago. It's for a box of the film strips, so you think it's a quick one. You find the label, grab a box off the shelf, label it, and send the customer on his merry way relieved that you no longer have to look at him.

Eventually, the other pharmacist returns to work, and you steadily grind down the mountain of prescriptions. At the end of the day, you actually filled only slightly more than normal for a Thursday, but it felt like 10 times that. Exhausted, you go home and pass out without even eating dinner. The only thought in your head is that you have to rest up, so you can be at the pharmacy at 8:00 the next morning to do it all over again.

Over a month later, a doctor calls you up inquiring about one of his Suboxone patients. The guy was complaining about having withdrawal symptoms and needing to increase his dose. The doctor couldn't understand why after being stable for so long the man was suddenly going through withdrawal, so he wanted to check with the pharmacy to see if you could perhaps shine some light on the mystery.

This month, the patient received the 2 mg Suboxone, just like the doctor ordered. However, the previous month, he got the 8 mg dosage. In fact, that was the only time he ever got the 8 mg dosage. Upon checking the prescription, you find that your initials are on the hard copy of a prescription that was filled in error. The man got 4 times his usual dose because instead of dispensing the 2 mg to him like he always got, you dispensed the 8 mg film strips.

Your error, while thankfully not harming the patient, caused the doctor to have to alter his treatment plan and increase his dose to accommodate for his withdrawal symptoms. The doctor reported the error to the state board of pharmacy, and 3 weeks later a drug control agent wants to speak to you about the mistake.

In the end, you don't suffer any serious penalties as no one got hurt, and it was your first offense. However, it's still embarrassing because you know how hard you work and how serious you are about being accurate. You're professional about the whole situation. Your initials are on the prescription. You missed the check. It's ultimately your fault, so you take the blame. However, you know that there were a lot of factors that contributed to that error. It wasn't just carelessness on your part. The error was part of the retail pharmacy culture that promotes speed, volume, and business-related paperwork over accuracy and patient care.

You were lucky this time. No one got hurt. Maybe the next error won't come with such good fortune. All you know is that you don't want to be around to find out.