Tuesday, January 11, 2011

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.


Pharmacy Chick said...

Sorry Mike. we have all been there and at no time does it get any easier to discover a mistake. How interesting that the dr chose to report it to the board. Next time a physician makes a prescribing error shoudl I be reporting it to the board of medical examiners? sheesh. so much for "team".

bcmigal said...

Mike, I really think that our current work environment promotes errors. If another medical care provider, or attorney or accountant had to endure countless distractions and interruptions, it would be on an episoide of 60 Minutes. I find it incredible that there are not many more misfills. As pharmacists, it seems that we have no recourse. We are penalized and punished, but the culture does not change.

Anonymous said...

Wow, Mike. Well said. In my 10+ years as a pharmacist, I have seen this happen over and over again. Honestly, I wonder if we pharmacists really spread the word about the DANGERS we face in our profession from the constant pressures if anything would change. I HAVE shared your post with others - maybe it will at least make them stop and think the next time they need a script. I have to ask myself, what in the world is the APhA doing to effect positive change in these situations??!!

Frantic Pharmacist said...

I too learned the hard way that rushing to get the 'quick' one done because you are being pressured is asking for trouble. Especially those run-of-the-mill amoxicillins, Zithromax, Augmentins that we see over and over -- I continually have to stop myself and make sure I have done more than 'glance' at it. It makes me angry that I have to fight against the pharmacy culture as you say, to take the proper time with prescriptions.

Tracy said...

Man, I'm sorry that happened. I know how easily it happens no matter how hard you try. I'm "just a tech", but feel that we have a responsibility as well. I know it isn't our license on the line, but it is our job to set up the pharmacists. We should be triaging the questions and the phone calls, handling the insurance problems. I am so sorry that your tech/clerks don't do this for you. I wish I could send you a couple of my awesome techs. (I'd need them back...). At least you could have a good Monday. We'd be screwed without them.

Anonymous said...

This is just unfortunate. I am also a retail pharmacist and has experienced irresponsible techs, misfills, craziness, ignorant customers, on and on and on. Yes i believe something needs to change. The distractions that we encounter is a prescription for disaster. Employers turn their blind side on this because all they want is profit. All i want is patient safety. Hence, i will not stop when i'm supposed to be verifying prescriptions to open the restroom door for a customer to make my DM happy. thats where i draw the line.

California pharmacy schools said...

Yikes-errors are always terrifying, even if they aren't your own you are still the one everyone blames! Part of the fun of being a pharmacist

Anonymous said...

Thanks for writing this up. I'm sure that the eloquent description will show up in more than one dispensing class this semester.

From the description, however, it sounds as if there was no way that something wasn't going to go wrong. There is a human limit to these things, and it probably easily had been surpassed within a few hours, whether or not there was time for a break.

Anonymous said...

Sorry you had to go through this. I've been a retail pharmacist for over 30 years and have seen many errors (ones I did and of course others). When its your mistake you feel bad enough but I have never heard of an MD calling the board. I came upon your blog because I just got home from work and am feeling like looking for another job outside of retail because its soooo crazy. Things have definitely gotten crazier behind the pharmacy in the last 5 to 10 years. With all the e-scripts errors from mds and the third party rejections, and formulary issues and lack of communication with the prescribers (just fax it over), the corporate programs and corporate monitoring of everything. I'm sick of it. I worked 8 hours today and didn't stop to take a bite of the sandwich I brought. I feel sorry for the young new RPhs that have to deal with this their whole career. I only have at most 10 years left, if I make it. Good luck hopefully things will change for the better.

Anonymous said...

I am not a pharmacist, Tech, or prescriber, however, I do have a comment and a personal story. First the story. I tried to fill a prescription written by a local MD for an opthamalic soultion the same night I received it and was only able to find it at one pharmacy. I was told by the pharmacy manager that he had the item, but only in a larger vial (10ML vs 5ML as written), but he could fill it with the 10ml quantity since I had a refill and it was cash. So the pharmacy manager left it on his shelf for me to pick up the next morning which was his day off. I phoned the pharmacy the next day to make sure he had done what he said and was told by the pharmacist on duty that the prescription was left out by her manager, but she would not fill it because of the quantity difference. She refused to contact her pharmacy manager because she stated that she did not take orders from the pharmacist/manager and she had the discretion to choose not to fill it if it was not identical to the written prescription. I find this stupid when it is obvious that the prescriber intended for the patient to have 10ml of this item anyway what difference does it make wether it is bought all at once in one vial or two vials? I have tried to find out online what the laws are in Georgia regarding this situation, but I cannot find that it a pharmacist cannot fill a prescription for a different quantity of the same medication unless it is for a controlled medication. Using the "professional judgement" standard which I keep reading about in blogs I would assume that it is up to the pharmacist. If so what possible reason would a pharmacist have to refuse to fill this 5ML RX with a 10ML quantity? This is why, as a patient, I feel that the regulations for pharmacists should be even more specifically written as to remove this area of discretion. If all pharmacists knew exactly what they had to do and they were required to do it then it would be easier for you to all do your jobs. You would not have to use judgement other than basic common sense to fill your prescriptions you would just have to do exactly what the law stated. Any comments I would love to read.

Anonymous said...

What I especially like as a floater is walking into some of these dumps that haven't been cleaned (well, when ARE they ever cleaned) Dirty dishes everywhere..trash...and being expected to give injections. If ever there was an example of useless State Pharmacy offices...this is it. Errors? Hey..built into the system..

Anonymous said...

Mike, any pharmacist working has made errors- if they claim they haven't, it just hasn't been detected... yet. I often feel a pharmacist's motto must be "no good deed goes unpunished". We bend over backward to get Rxs out in a timely manner, take abuse from MD's and customers, deal with insurance issues out of our control (all of this while getting constantly interrupted) and ultimately the buck stops with us. Consumers happily wait longer for a reserved dinner reservation than for an Rx to be filled. We are a trusted, conscientious profession that gets abused in spite of our willingness to help people. There is such a low threshold for error so we live in fear after a long, hectic day that we have not made any mistakes.

RealPharmer said...

Ga Law -
§ 26-4-81. (For effective date, see note.) Substitution of generic drugs for brand name
(a) In accordance with this Code section, a pharmacist may substitute a drug with the
same generic name in the same strength, quantity, dose, and dosage form as the
prescribed brand name drug product which is, in the pharmacist's reasonable professional
opinion, pharmaceutically equivalent.

I take that to mean that the pharmacist that was filling the prescription did not want to change the quantity. It is their licence, and they were correct they do not have to fill a prescription that they do not feel comfortable with. Was he/she being an ass? yea probably but hey, it was not my licence.

RealPharmer said...

Anonymous Feb 18th..
It would make my job easier, If you knew how many mistakes that we catch coming from a prescriber you would think differently. We are another safety net for you, more often than not we fix things that you never see or have to deal with because we are that good. That Rx you can't read but maybe 20% of the time we can, we do, and we also know when it's time to call to verify. We watch what meds you are on, oh 2 statins time to call the doc and/or you and tell you to not take both. That HCTZ/Lasix you were told to take every day? We are the ones that make sure you don't take it at night, get up to use the restroom and break something because you were up four or five times during the night. If you let us we will save you money, if we are recommending you use the generic/different product entirely we have a good reason and most of the time you would do well to at least listen. I know the las bit has been all over the place, but I feel that you don't understand what we do, and it seems like very few people actually get it. We are not supposed to be machines counting and handing you a bag. I can not speak for the pharmacist that refused to fill your eye drop, but I am sure they felt that they had a valid reason. That is the price of having yet another safety net that can think for itself, sometimes it will get frustrating it is better than hitting the ground.

CanuckRx said...

I read many of the posts and comments and thought it all sounds too familiar. I am a retail pharmacist working in Canada for 8 years and we have the same problems with workload/multitasking and general job dissatisfaction. You mention dispensing errors correlating with workload a few times. I agree. At one of the places I worked at, the pharmacy manager saw fit to go after me because at 150 -180 scripts per 8 hr shift working alone, I was identified as the weak link and needed to go faster. I informed him I would not because of the increased risk of dispensing errors and suggested he hire more pharmacists instead. We, at one point, had 3 full time pharmacists doing less Rx's and by this point, I was the only one left. Nobody was hired, so I got fed up and left.

The irony was, the manager, also a pharmacist, was in the process of filling out incident reports because he allowed a patient to receive 100 mg morphine capsules instead of 10 mg capsules. This put the patient into respiratory distress which required hospitalization. I now work elsewhere, at a semi-independent, pharmacy focused retail store. I don't have that fear of screwing up anymore. There are other issues though...