Pharmacy Dreams

I'm sure every pharmacist gets dreams like this every once in a while....

This morning, I woke up at 5:00 AM in a panic. I was having a dream that I made an error during my previous workday, and I was just realizing it in the middle of the night.

The error was due to the doctor's poor writing and me being in a rush. The prescription read "Norvasc 10mg, #30, QD." However, I misread the prescription as "Norvasc 10mg, #30, TID." Hours later, I realized that taking Norvasc 3 times a day doesn't make much sense, and this is how I realized I made a mistake.

Of course... This didn't actually happen. It was just a dream. However, it felt so real, and it was so plausible that it made me nervous. I kept trying to tell myself that I know it's just a dream, but being not quite awake yet, my mind wouldn't let go of the belief I made an error. I actually had to open my eyes, roll over, and stare at the ceiling for a little while before I could believe it was all just a dream.

Despite it not actually happening, this does illustrate one of the potential pitfalls of working in retail pharmacy. At times, you can get so caught up in checking individual prescriptions that sometimes you don't stop to ask yourself if the prescription makes sense. You just make sure that the info written on the prescription is what makes it to the label.

For example, yesterday, one of the pharmacists checked 2 prescriptions for the same patient. One was Fluoxetine 40mg, QD, with 2 refills. The other was Lexapro 10mg, QD, with 2 refills. That's obviously a therapeutic duplication as they are both SSRIs. However, the pharmacist (it wasn't me) just checked them and kept on going. Both were filled exactly as the prescription stated. However, no one even thought to question why the patient would be taking both drugs at the same time. (I called the doctor today, and it turns out that he, indeed, meant for the patient to be taking both, but that's besides the point).

I've made 2 significant prescription errors (that I know of) in my time as a pharmacist. Significant errors don't include miscounting tablets, putting the wrong doctor's name, or the wrong amount of refills on a prescription. When I say significant errors, I mean making a mistake on the drug, dose, or directions.

My first error was entirely due to an interruption during the filling process. I was working by myself in an extremely slow store. I got a prescription for Prednisone 20 mg. I typed it incorrectly for Prednisone 10mg. I was about to check the script, but the phone rang. I picked up the phone and spent 5 minutes answering some sort of questions (I can't remember what). During that time, the customer came back to the counter expecting to pick up the finished prescription. By the time I hung up the phone, I forgot that I didn't check the script, and I filled what was on the label. Two minutes after she walked away, I realized I never checked the script, and this is where I realized I made a mistake. I promptly called the patient to tell her I made a mistake, I corrected the prescription, and refunded the patient her money (all $1.XX worth). I felt so bad I was on the verge of tears when I was refunding her money.

My second mistake came on a Saturday at my current store. This occured nearly a year ago. I got a prescription for Avinza 30mg for 60 capsules. I typed the prescription correctly. However, I filled the prescription with Avinza 60mg capsules. Avinza is an extended release Morphine, so this obviously could have been a pretty significant mistake. You never want to mess up a morphine script, and you especially don't want to give too much morphine to a patient. I didn't realize I made the mistake until hours later. At the time, our pharmacy manager got us in the habit of posting all our CII scripts in our perpetual inventory logbook at the end of the day instead of right after filling the script. Therefore, when I went to post the Avinza script, I realized that I filled it incorrectly.

I flipped out. I ran around the pharmacy tearing through the bins to see if it was still there. Unfortunately, the patient picked it up already. Then, I called him, but got no answer. I called one of the other pharmacists (who had 17 years of experience at our store). She told me that it wasn't a big deal because this particular patient had been on Avinza for quite some time. She told me to try him again in a little bit. I did and finally spoke to him. I found out he had already taken a dose, but he felt perfectly fine. Regardless, I told him to come back in, so that I could correct my mistake. Once again, I felt very very bad about the mistake (the customer wasn't mad at all though. He was quite nice about the whole thing).

Those are the only 2 significant errors that I've made that I know of, but I've had to explain other pharmacists' errors to customers, and that's never fun. The customer is mad, and understandably so, that a mistake was made, and they are directing their anger at you. However, you can't tell them it wasn't your fault. You don't want to go and pass the blame on someone else, so all you can do is apologize profusely, refund their money, and hope that this appeases them.

Anyway... I just wanted to write something. Things aren't looking too good with eHarmony girl. She hasn't called or emailed me in a few days. I'm pretty sure I blew it with her. It sucks because I really liked this girl. Looks like I'm back at square one... again.