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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  1. Leo M Lawless

    Even pharmacist are human do make errors the important thing is identify any contributing factors and learn something from the mistake, All our errors can teach us something, Paying that little extra attention to high risk medications is something I think we have all learned, In a recent study, which I forget the source but believe it was Great Britain, on 39% of pharmacist caught purposeful errors in 50 prescriptions they were given to fill over 25 minutes, Is there a lesson there? Perhaps we to willingly accept and allow production quotas.

  2. Mackey Jesse

    Thanks Brian,
    Before signing any script, we should double check with a colleague or even a well trained tech. Four eyes are better than two! Never allow your subordinate to sign off any prescription because your input matter.
    Even Pharmacists make mistakes. The best thing is that we should own up, but before we get there, let us slow down when dispensing medications with narrow therapeutic window. For the worst case scenario, every practicing Pharmacist need to have a Professional Indemnity Cover.
    PI does not fortify the Pharmacist against the mistakes, but against some clients who would prefer the legal option.

    • Leo M Lawless

      By learning from each error, its cause, contributing factors, we can put in place procedures to minimize if not out right avoid its happening again. No one want’s to make even a single error and that should properly be our goal but we cant beat ourselves up when one occurs, we identify it and it causes and contributing factors and remove those from the process, Having insurance or such occasions I wise, but should not make us feel any error is acceptable, because its “covered”. We also have to be willing to stand up to management when volume and staffing are just not the right mix and we cannot do our job properly and fully, We have an obligation to our patients, but we also have an obligation to ourselves.

  3. Dipali Kadiwar

    So true esp on NTI meds like Warfarin, Synthroid & Phenytoin. I always question Bid dosing on Warfarin & Synthroid.

    • chri1599

      Agreed, haven’t seen a rationale for it yet!

  4. Dipali Kadiwar

    Very hard to do but we have to find balance between business & clinical sides of pharmacy.

    • chri1599

      Not something we like to talk about, but necessary evil…

  5. Roger Brown

    Warfarin’s half-life along with the half-lives of factors 2, 7, 9, and 10, do not support twice daily dosing. Pharmacy software needs to be developed ( or utilized) which calls attention to more than one daily administration time or when multiple strengths are administered on the same day. Modification of systems can help to prevent this type of error.

    • chri1599

      Continuous improvement of computer software is an important aspect, continuous improvement and application of critical thinking on the practitioners part also helps patient safety!

  6. Allana Alexander

    Dear Brian,

    Thanks for sharing this! I double check everything, however there are certain medications I triple-quadruple check LOL…I’ll add warfarin to this list!!! I’m a new pharmacist, and I know to err is human, but medication errors are still SCARY!! Reading articles and posts like this is very helpful in the endless pursuit of being a great pharmacist. Thanks again for posting!

    • chri1599

      Med errors are scary! – Recently saw a Lantus/Humalog mixup! Ended up ok, but scary for sure!


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Written By Eric Christianson

September 14, 2014

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