Medication Mistakes can be Stepping Stones to Better Care

Ever made a mistake? I have. I will never forget that feeling – it’s awful.

I was reviewing a patient’s medication list and noted that the patient was struggling with the costs of their medications. I was a fairly recent new graduate at the time and the patient was taking Lipitor (brand name) at the time at a dose of 10 mg. I suggested that we change it to Zocor (simvastatin) 20 mg which was generic and much cheaper – a recommendation I had certainly made before. What I failed to realize was that this patient had an intolerance to simvastatin that was on their allergy list. (By the way, this is why we have multiple checks in place to prevent one person’s mistake from getting to the patient) I flat out missed it. I remember coming across it at a later date (which I’m very thankful to be able to learn from this without patient harm), and found that a wonderful nurse had caught my error and prevented a negative outcome. When I went to thank her for catching the error and saving me, she was totally oblivious and could hardly even remember it. Medication errors happen because we are imperfect people trying to serve our patients perfectly. I tell you this story, because it’s real, and it happens. We all must learn from our own mistakes, as well as the mistakes of others to continuously improve the quality and safety of our care. Paraphrasing Vince Lombardi, “Relentlessly pursue perfection, and along the way you’ll catch excellence” To the nurse who I’m sure doesn’t remember this story by now – Thank you. We really are all in this together.

Thanks for reading!  I’m giving away a 6 page PDF on 30 medication mistakes I see in my practice, please take advantage of the free and unique opportunity!

Written By Eric Christianson

April 23, 2014

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