The Pharmacy Chick

Flying the coup in retail

Two Errors, two different reactions.

Filed under: Uncategorized — pharmacychick at 6:26 pm on Wednesday, November 18, 2015

On Friday  night Pharmacy Chick was driving home from work.  It was dark, raining and I was very tired. Yet, as I approached this intersection, habit took over and I looked right and left before I entered it….and doing so spared me the impact of a young lady running a red light at high speed.  I slammed on my brakes and she missed me but she hit the car coming from my opposite direction.  By the grace of God, ( no comments please, its MY blog after all) she only clipped the front end of the car instead of T-boning her head on, which would have surely caused injury to both.  In the aftermath, I pulled over, went to the closest car ( the HittER) and told her to IMMEDIATELY call 911 and said ” You do realize you ran a red light right??” She assumed all responsibility for what she did.  I then ran to the other car ( The HitEE) where another driver had stopped to assist her.  She was startled and a bit disoriented but physically unharmed. All parties met at the side of the road.  I could hear the sirens so the police were nearby.This girl had made a grievous error by running a red light.

For all intents and purposes HitEE had every right to be angry and indignant. She could have been killed at the most, and harmed at the very least with a direct hit. What did she say to the HittER?  ” ARE YOU OK?” .   It was a twenty-something girl who hit the other car.  I can’t begin to assume what she was doing ( or not doing) when she sped thru the intersection..and “didn’t see” the red light.  Was she playing with her phone?  Fiddling with the radio?   It doesn’t matter at that moment, and it wasn’t my business.  As a witness on a dark night I only saw HittER run the light and hit HitEE.  What I also saw was GRACE.  She said ” Im ok it was an accident.. we are all alive”. HittER was apologetic and upset at what she had done.    HitEE wasn’t angry. She wasn’t indignant. And, to be honest, I am not sure how I would have reacted if I had been struck.  I might have asked what she was doing  and if her phone was involved.Im do not tend to be an over-reactor but I haven’t been nearly killed in a car accident either…. But…this wasn’t my story or my error to react to. It was hers to own and she chose a forgiving and accepting response.

In Sept I made a filling error on a prescription.  I transcribed Atenolol 50mg instead of 25 on a prescription that had been e-sent to us.  This patient was a long timer.  15 years or so.  We had a (what I believed) to be a great pharmacy patient relationship.  She had been on 25mg for a long time.  She took the 50s for a month or so before discovering the error.  She had felt ” a little more tired and my resting pulse was low” –her reports when I asked her about any ramifications.  She had reported the error to my other pharmacist who contacted me. I called her immediately, made sincere apologies…asked if she had any harm ( no), and asked if there was anything I could do for her at this time ( No)  This error had my initials on it so I owned the error.  She also owned the error.  I made it and she controls whatever response she wants to it.  Its hers and her right to have any response to having a pharmacy error she wants.  I can’t make that decision but i have to live with it and respect it.   She chose to be angry, unforgiving and indignant.  I was surprised simply because this wasn’t the kind of person she had showed us to be over the last 15 years but then again,  everything had gone well and perfect for 15 years.   My apologies went un-accepted and nearly un-acknowledged.  She at least said ” I know we are all human and make mistakes….( but then we got the butt-sandwich)  BUT I dont think I can trust you again. I may have to transfer out”.

All I could say to that is ” I understand. This is a decision only you can make and I will support what ever you need to do, again I am most sorry”.

Clinically this is a pretty mild error. It wouldn’t have had any long term impact on her health or well being.  But its an error and no error is the fault of the patient. But to her it was as big a deal as if I attempted to kill her…

Any error upsets me. I try to be careful and accurate every rx every day.. But I am more upset that I am un-forgiven. If she does decide to stay, I am sure I will get to be her punching bag for a while as she vents this out.





Comment by murgatr

November 19, 2015 @ 7:01 am

Have been on both ends of traffic accidents (victim & at fault). Keeping a level head & taking emotion out of the situation is best for all parties involved. Bummer on the medication error, it happens but doesn’t seem likely that you will be forgiven anytime soon. Take Care Chick!

Pharm. Tech. RDC’06

Comment by Liz Harris

November 19, 2015 @ 2:20 pm

Re: Prescription error:

And this is exactly why I check the medication label and the actual tablets for size and color when I pick up a refill for the one script I take.

Errors happen. It’s human nature. But it’s MY responsibility in the end to ensure that the refill is correct.

You’re better off without her.

Comment by Brant

November 20, 2015 @ 11:54 am

She has 50% of the blame. If she isn’t checking what is handed to her she’s just as much at fault

Comment by PharmacyJim

November 20, 2015 @ 4:41 pm

Having read this blog for a long time, and been in PC’s shoes a handful of times in 35 years (thank God no one has been harmed), I can guess NO one feels worse about the mistake than PC. But,yes, we are human and it will happen and the buck stops with us. How people react to those stresses we have no control over. Hang in there, PC!

Comment by Emma

November 20, 2015 @ 9:29 pm

The fact that she received 50mg tabs instead of 25 is your error. The fact that the error continued for a month with the patient taking a different tablet than she has for years without once questioning the differences in size and markings is not.
I get it. I have not made many errors in my career, but every one has upset me, probably for longer than the patient. However, there is a corresponding responsibility on the part of the patient to be aware of what they are ingesting. Not just your fault.our company subscribes to the opinion that an error is never the customers fault and that they have no responsibility whatsoever to assure they received their meds correct. Therefore, I am bound by that opinion whether I share it or not 🙂

Comment by Jade

December 4, 2015 @ 8:23 pm

I was brought up short one time by an error I made in a hospital pharmacy with a retail license for employees when I was working for an agency. I usually knew everyone at my regular job, but this was in a shop in another town, and I knew no one there. A nurse came to the window and asked for her prescription, and I went to the bin, retrieved it, bagged it with the receipt showing her name, handed it to her and asked if she had any questions. She said, ‘no, I’ve been on already’. The next day she brought the matter to the manager’s attention that I’d given her someone else’s prescription (with a similar name) and had taken a dose. I erred. I realized I had to come up with a method to ensure that I was giving the correct prescription to the patients. But, I did have to consider this was not entirely and completely my error.

Usually, I try to provide the most chances for eliminating an error, in what I do, telling the patient about the name of the drug and asking how it’s working for their specific ailment, how I don’t cover drug labels, how I position the receipts, counsel (or give the opportunity to counsel), etc., so that there is some meaningful conversation.

For prescription mills, and drug warehouses, it was probably the best thing when prefilled 30 days quantity bottle were made available, bar-coding and other measures were put in place, without the patient interaction.

Comment by pharmacychick

December 11, 2015 @ 5:19 pm

At PharmacyChick pharmacy everyone has to verify their date of birth. This eliminates the “wrong patient” errors, but doesn’t fist the wrong drug errors sadly. The fact is that anything has the potential for an error. even machines make mistakes. we will never completely eliminate errors from any workplace. All we can do is reduce them with proper diligence.

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