Wednesday, March 9, 2011

Another Prescription Error That Could Have Easily Been Avoided

I'm going to turn this blog into ranting and raving against the forces in our profession that seek to put the public in danger. My focus will be on prescription errors, and how often the simplest of things can help avoid them.

Our pharmacy had another prescription error last week. This one, to my knowledge hasn't been reported to the Board of Pharmacy. Although, I almost wish they would report it because I would go before the board intent on kicking up a shit storm.

A customer presented to our pharmacy counter carrying 3 prescriptions. For the sake of this entry, we'll say this customer's name was Thomas Richards. Thomas has been on pain medication for quite some time. He's had several recent procedures that have required him to get a number of different pain meds. His need for opioid pain medication is perfectly legitimate. He is not the problem here.

The 3 prescriptions were for 3 different pain medications. They were from the same doctor's office, written in the same pen, and given to the patient at the same time. The technician at the drop-off counter, added Mr. Richards' date of birth and address to all 3 prescriptions, and told him the scripts will be ready for pick up in about 20 minutes. Everything was seemingly going smoothly.

The other pharmacist on duty was the one who inputted the prescriptions into the computer. He noticed that the doctor had given Mr. Richards prescriptions for MS Contin, Dilaudid, and Percocet. He wondered out loud why the doctor would give this patient both Dilaudid and Percocet. However, since that office is an orthopedic group, and we see a ton of interesting pain med combinations from them, we just kind of shrugged it off. I've seen patients get prescriptions for Percocet designated for moderate pain and Dilaudid designated for severe pain. It's not that common, but not unheard of. Therefore, we decided to just let it go. After all, it wasn't like they wrote the scripts for large quantities, and Mr. Richards was certainly in pain.

Twenty minutes later, Mr. Richards comes back and his prescriptions are all set for him. He pays and goes on his merry way. Several hours later, he calls the pharmacy saying we made a mistake. He said that the prescription couldn't have been for Percocet because he gets very ill when taking it. The doctors know that and wouldn't prescribe him that. The script was supposed to be for Flexeril.

I look back and double check the prescription. It most certainly said Percocet 5/325. I quickly checked the name and date of birth (that we had to write on the prescription when he dropped it off). Yes, it was filled correctly. Mr. Richards sighed and muttered something about the dumb doctor's office, and hung up. A little later the prescription for Flexeril was callled in to us. I guessed that he must have let the office know of the mistake.

Several days later, we get a call from that office. "The prescription you filled for Thomas Richards for Percocet was filled in error," proclaimed one of the nurses. "Mr. Richards was never prescribed Percocet. That prescription was for Thomas RICHARDSON."

Sure enough, when I went back and triple checked the script, the name on the top was Thomas Richardson, not Thomas Richards. It was a prescription error.

However, let's back things up just a little bit. How the hell did Thomas Richards get Thomas Richardson's prescription?

You see... This is a practice that I think is unfamiliar to the general public. Doctors don't actually physically write most of their prescriptions. They usually have a nurse write them, and then they sign their names at the bottom. We see it ALL THE TIME. The patient's name and all other prescription info will be written in these big, bubbly, girly looking letters, and the doctors signature is scribbled at the bottom. It doesn't matter whether we're talking about prescriptions for blood pressure medications or for Oxycontin. Many doctors don't write their own scripts.

Secondly, the only conceivable way that Mr. Richards was given Mr. Richardson's prescription was if the prescription was written out ahead of time and stored in some kind of file at the doctor's office. Obviously, the doctor or nurse did not see Mr. Richards and Mr. Richardson at the same time. If he was only writing for one patient at a time, there's no way that one patient could have come into contact with another patient's prescription. The only possible way was if a nurse had to sift through a file to find Mr. Richards prescriptions, and it just so happened that Mr. Richardson's script was mistakenly filed under the wrong name.

Moreover, the patient's address and date of birth was not written on ANY of the 3 prescriptions for schedule II controlled substances that Mr. Richards dropped off. The technician at drop-off had to inquire to the patient's address and DOB, and she was the one that wrote them on all 3 prescriptions.

Therefore, when the scripts finally made it to the pharmacy, all 3 of them were written in the same pen, from the same doctor's office, on the same prescription blanks, dropped off at the same time by Mr. Richards, and all had the same address and DOB on them (because the tech wrote them in on all 3). However, one was for Mr. Richardson instead of Mr. Richards.

The nurse who called to tell us about the error gave me the "YOU FILLED IT WRONG!" attitude, and quite frankly it really pissed me off. Yes, I suppose ultimately, it was a pharmacy error. However, the patient, the technician, and 2 pharmacists both looked at these scripts and didn't notice the slight difference in the name on one of the prescriptions.

It goes down as a pharmacy error, but if the doctor had A) not written the prescriptions ahead of time, and B) had included the patient's address and DOB on every prescription (which by LAW, they are supposed to), we would have easily caught the mistake.

It's just another incidence when pharmacies are the ones getting shit on for prescription errors, even though we're seemingly the only entity in all of health care the gives a shit about doing things to prevent them. Every time a doctor writes sloppily, every time he uses unapproved abbreviations, every time he doesn't include the patients date of birth and address on the prescription, and every time he doesn't provide his DEA #, there is a chance for a prescription to be either misfilled or therapy to be delayed to a patient due to the pharmacy's attempt to try to fill in the missing information.

Everyone laughs about doctors' messy handwriting. It's a big fucking joke. The public just assumes that's the way it is, and it isn't going to change. If the pharmacy can't read what the doctor writes and has to call to verify a prescription, the patient gets mad at us and not the doctor. The public jumps all over pharmacy mistakes, but the doctor can write illegibly, prescribe the wrong dose, wrong drug, or a medication with a significant drug interaction, and the public just shrugs it off.

Why is everyone so afraid of doctors and people in their offices? People come in and treat the pharmacists and pharmacy staff like dirt on a regular basis. They yell and scream about customer service. They look to us to fix everyone else's mistakes, and then get mad at us when it can't be done in 5 fucking minutes.

I'm sick and tired of it. I really am. I can't be the customer service representative, insurance trouble shooter, I.T. help desk, store printer technician, cashier, secretary, business manager, AND pharmacist at the same time. Every time you interrupt me with something that isn't related to verifying the safety and accuracy of prescription orders, the chances of someone being harmed by a pharmacy error increases. Every time my District Manager requires me to personally walk customers directly to any item in the store that they might be looking for, I'm interrupted from possibly teaching someone how to use an inhaler or inject insulin.

I'm a pharmacist. I'm not a fucking customer service rep. I'm not a fucking cashier. I make sure prescriptions are safe, accurate, and that patients know how to use them. Everything else is superfluous. I don't give a shit about the fucking inventory being over budget. Get an ordering department. I don't have time to spend 2 hours on the phone with an insurance company to get a claim to go through that provides a $2.50 profit. Get a billing department.

I know I'm kind of ranting off topic now, but my overarching point is that we're asked to do too many things at one time, and even asking other medical professionals to take literally a few extra seconds to write patients' addresses, DOB's, and prescribers DEA #s on prescriptions seems to be too much of a hassle for them. It would literally take 5 extra seconds, but they can't be bothered, and because they can't be bothered, the chances of pharmacy prescription errors increase.

If you're a prescriber reading this, and you're one of these fucks that don't take those 5 extra seconds, FUCK YOU! Seriously, you're scum. You make pharmacists lives miserable because you're too fucking lazy to do what you're supposed to.


Anonymous said...

I only see about one hand-written Rx a day, It's 2011, surely a Dr can produce a Rx on a standard sheet on a cheap laptop/inkjet printer that autmoatically includes dob/address, etc?

I'm in the UK and for at least twenty years we've had computer-printed Rx. yes, we still make mistakes, but it's a different type of mistake :)

Frantic Pharmacist said...

Yes, apparently the doctor's office feels no responsibility for handing a patient a prescription with someone ELSE's name on it. We see this all the time with people who walk over from the urgent care clinic with a computer generated prescription with a name NOT their own. It is playing with fire and we are the ones likely to get burned. Joint Commission standards require the use of 2 patient 'identifiers' before a medication is administered --- not sure why that doesn't apply to prescriptions in a doc's office.

Ashley Mc said...

At the ER with my mother a few weeks ago, we're about to leave and the nurse comes over with all the discharge info.

Handing me the Rx's while my mother listens to instruction, I'm a little surprised at the Lortab Rx...b/c she didn't complain of pain.

Lo and behold the Rx was for someone else. HIPAA out the window. "oops! wrong chart" was all we got.

If we sell a script to the wrong patient, we're obligated to tell the patient who's Rx was sold to the wrong person about the incident...b/c of HIPAA. I wonder if the nurse explained that to the other ER pt.

Or if the MDs ofc did in your misfill story.

Nathaniel said...

I always stress that we are having problems becasue it was the Dr's office's error not ours and if they are upset they should speak with them. Many times pharmacies fail to explicitly state this so the patient is kinda in teh dark. I've had many patients claim they were gonna call the office and tear it up becasue there was something wrong with their RX.

Anonymous said...

wow. that is so effing dangerous. those incompetent mofuckers!!

The Nail Narc said...

That is NOT a pharmacy error. Clearly, the root cause is the doctor's office handed the wrong patient the wrong prescription! I wouldn't even turn it in as a pharmacy incident. Plus, I'd be writting a letter to the physician's practice telling them exactly what happened and what caused the problem.
How could anyone reasonably assume an RX handed to them by a person who claims all the RXs are for him, be handing you an RX for a person with the same name or almost exactly the same name, but not know it?! What if the other guy's name was also Thomas Richards!? Same result would of happened. So, yea, not your fault!
Maybe I'm a fucker, but I'd call the DEA and make sure there is an inspection done at that pain clinic.

Historically Crazy said...

People are less afraid of someone in an office than someone across a counter is my opinion.

Anonymous said...

I had similar incident happened at CVS while I was working and I explained to the customer that I had to call the doctor's office for verification. The customer was upset because the doctor wrote someone else's name but it supposed to be for her. She complaint to DM and complaint that I was giving her hard time and that I gave her problems before, etc.. and regardless what I had to say, DM stated I was argumentative with customer and it count against my review, etc, even after I told him that I was following the DEA Law!
Don't ever work for CVS!!!!!

PharmGamerKid said...

I had an Indian guy (let's say his name is Mr. Patel) walk in with a promethazine DM prescription for a Mr. Rodriguez (who is also a regular at our pharmacy but w/ different DOB). My first instinct: did he steal a prescription? but why would anyone bother stealing a prescription for promethazine DM. We ask the patient on it, and he finally looked at the prescription and was like WTF?!? Do I even look like a Rodriguez?!?!? We called office. Turns out, MD started to write for Mr. Rodriguez, but then changed his mind and didn't prescribe anything. Then, he reused the same pad to write for Mr. Patel (w/o paying attention to the name at the top or maybe just leaving for nurse to fill out the name).

And let me guess, Thomas Richards probably looked like Thomas Rich[scribble scribble]