Humans – Prone to Error; A Candid Guest Post on a Personal Mistake

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Another guest post tonight via Brian Catton, PharmD!

As a pharmacist, although I realize that I’m prone to error due to my humanity, I dread hearing that I committed a medication error. One January day proved to be the case.

Medication Error pickup-walmart

Back in November, BZ, a 70+ y/o male, received a prescription for Warfarin 5 mg with the directions, “Take 2 tablets by mouth daily.” When I checked it, I misread the prescription and thought the directions read “Take 2 tablets by mouth TWICE daily”. BZ is very compliant on his medications, and took his tablets as directed. When he visited his cardiologist in January, they conducted blood work on him and discovered his INR to be 9 (normal should be between 2 to 3). In that case, my first thought was of dread for the patient (i.e. if he suffered any internal bleeding, severe bruising, or any other bleeding complications). Fortunately, he only suffered minor bruising and didn’t experience any other severe complications.

Moving forward from that dreadful experience, when it comes to dispensing medications with a narrow therapeutic window (e.g. levothyroxine and warfarin), I slow down enough to make sure that everything on the prescription is correct. Moreover, when patients pick up their medication(s), I make sure they are alerted and consulted by the technician about how to properly take their medication (if the directions are not the typical one tablet once/twice daily). Although BZ was compliant, I sadly must assume most patients are not like him. Reviewing the directions with the patient directly at point-of-sale will result in improved compliance and decreased risk for medication errors. By altering my pharmacy practice methods with this direct reinforcement of medication directions, I will uphold one of the vows from Oath of a Pharmacist to “consider the welfare of humanity and relief of human suffering my primary concerns.

Brian J. Catton, PharmD
Staff Floater Pharmacist: CVS Health
Pharmacy Contributor: PharmPsych Online Pharmacy Magazine
Recipient of the 2014 Pharmacist Mutual Distinguished Young Pharmacist Award with the New Jersey Pharmacists Association

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Written By Eric Christianson

September 14, 2014

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