Med Error

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Hello all,

I don't really know what I'm looking for by posting this, I guess just a little encouragement and advice. So, I work at a pharmacy and am currently in nursing school. I'm still doing my pharmacy tech training so I mostly just sell prescriptions, put in for refills, etc but I don't really handle the drugs yet. Last night a lady came in upset because her Dr hadn't called in her script yet. She had a little girl with her and they called the dr back and patently waited until the Dr finally got the fax in. Her script was for Tussionex and it was for the little girl. Our in store wait time was for like an hour but we tried to hurry and get her script ready. We got it done and her insurance didn't cover the med. The lady was angry that she waited so long and she was never informed that it wasn't covered but ended up paying cash for it anyways.

Later on that night I hear the pharmacist on the phone with her. I was upset that this lady was taking up 30 minutes on the phone with the pharmacist and causing more of a backup when it was a problem with her insurance, not us. The pharmacist was acting kind of odd though and he had one of the techs delete that script out and doing all this stuff with it and I heard him tell the lady that she would get a refund but he was still being kind of secretive. My thought was wow, somehow this lady has convinced the pharmacist that she deserves a refund because her med wasn't covered. Whatever though, his call, not mine, so I moved on.

Fast forward to today. The pharmacy manager (not the pharmacist that was working last night) was working when I got to work and I told him that this lady had called and held up the pharmacy for 30 minutes last night and he was like, well, her insurance doesn't cover the med, there is nothing we can do about it. He didn't seem to know anything else about the situation. This lady comes in later after the pharm manager had left and tells me that she needs her refund. I ask her if there has been a change in insurance and she said no, that we filled her script wrong. She started to explain and all of a sudden I figured out why everyone was being so shady last night. The Dr faxed in a script for 1cc q 12h and the med was filled for 5ml q 12h. This little girl was 4 or 5 and the script was filled for 5 times the dosage. Thank god the lady caught that the dose was high before she gave it to her little girl; that could have possibly killed her. The lady was so upset (and rightfully so) and said that she was in the medical field but if she wasn't then she would have just given the med and not thought a thing about it.

Anyways, I'm pretty sure that this might have been covered up by the people that made the med error. I know I need to mention this to the pharmacy manager because IMO, this is a huge deal. This isn't like someone was shorted a pill or we took too long to fill their med, this could have seriously injured a little girl. I just don't know how to go about reporting this. I feel like I have a good relationship with my pharmacy manager but I don't want to go in and be a tattle tale if maybe this has already been reported. Ugh, I just don't know what to do. If they did cover this up and got fired or something, I would feel personally responsible for this happening. I'm and honest person (heck, I told my nursing instructor that my grade was wrong on my test knowing it could easily bump my test down a letter grade) and this just worries me. Anyways, any advice? I feel like crying and I didn't even do anything wrong :(

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Specializes in ICU.

The prescriber and pharmacist are both responsible for not realizing that was an unsafe dose for the child.

Are you sure the script was deleted out of the system, and not just flagged as an error? I want to give the pharmacist the benefit of the doubt and assume he is taking care of this through proper avenues - plus, it wouldn't be hard to prove the error - the customer had the prescription and reciept, and the doctor probably has a record of the script. And there would probably be evidence of a refund in the cash counting down records (wouldn't that involve a manager anyway?), and the med will be missing from the stocks in the overdose amount. I doubt this will just go away because he gave the customer a refund, and I'm sure if he has professional integrity he will follow whatever course of action he is required to in this situation. This could easily bite him in the behind if it resurfaces and he tried to cover it up, and I would like to think someone with that level of responsibility would think something like this through more than that.

Anyway, if you feel like you need to report it - that it's not getting addressed by your pharm manager - don't feel guilty. I would approach it more in a "I'm concerned about something that I may have seen" than a "I saw the pharm cover up a serious error!" manner. You didn't do anything wrong. If someone gets fired as a result of this, it sure sounds like they deserve it. *None* of this is your fault.

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Specializes in Neuro/ Tele;home health; Neuro ICU.

It needs to be investigated if what you suspect is true.

"I'm pretty sure that this might have been covered up by the people that made the med error. I know I need to mention this to the pharmacy manager because IMO, this is a huge deal. This isn't like someone was shorted a pill or we took to long to fill their med, this could have seriously injured a little girl" i think you have already answered yourself!!!

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The prescriber and pharmacist are both responsible for not realizing that was an unsafe dose for the child.

Are you sure the script was deleted out of the system, and not just flagged as an error? I want to give the pharmacist the benefit of the doubt and assume he is taking care of this through proper avenues - plus, it wouldn't be hard to prove the error - the customer had the prescription and reciept, and the doctor probably has a record of the script. And there would probably be evidence of a refund in the cash counting down records (wouldn't that involve a manager anyway?), and the med will be missing from the stocks in the overdose amount. I doubt this will just go away because he gave the customer a refund, and I'm sure if he has professional integrity he will follow whatever course of action he is required to in this situation. This could easily bite him in the behind if it resurfaces and he tried to cover it up, and I would like to think someone with that level of responsibility would think something like this through more than that.

Anyway, if you feel like you need to report it - that it's not getting addressed by your pharm manager - don't feel guilty. I would approach it more in a "I'm concerned about something that I may have seen" than a "I saw the pharm cover up a serious error!" manner. You didn't do anything wrong. If someone gets fired as a result of this, it sure sounds like they deserve it. *None* of this is your fault.

Well, the dose prescribed was safe. The script was written for 1cc (1ml) every 12 hrs, but when the script got scanned in and typed into our system, someone typed it in for 5ml every 12hrs and it was verified by the pharmacist that way and sold that way. The pt had never seen the script to know what it said since it was faxed in, and if she didn't have any medical knowledge she would have just given the med like the typed up label says.

I want to give the pharmacist the benefit of the doubt but it really seems like nothing was every reported. The records of the med sold are still in the computer (I went and checked tonight) and the script is still in our files I'm assuming, but the pharm manager obviously didn't know anything about this lady needing a refund based on the way he responded to me today when I vented about her clogging up our phones for 30 minutes last night. Bleh, this is just a crappy situation all around.

Thanks for your advice and encouragement! I'm thinking about saying something like, Hey, that lady who had the wrong dosage on her Tussionex came in for her refund last night after you left. Did you need a copy of the leaflet or receipt or anything? If he knows about it then he can just say yes or no if he needs a copy of anything for his report, and if he doesn't know about it then I can go from there. Does that sound ok?

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I'd stay out of it unless this guy makes a lot of errors. He knows he made an error. I'm sure he feels terrible about it. People make mistakes -- even people in the medical profession who know they need to be careful. Why do they make mistakes? Because they're incompetent, or because they're human? When you become a nurse you'll see how easy it is to screw up.

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I suspect firstyearstudent won't make it past 5 with the attitude of "staying out of it" and "when you become a nurse you'll see how easy it is to screw up."

It's just as easy to do the right thing and saves a lot more time, improves patient safety, and improves customer satisfaction. You only need to raise the concern and facts to your manager - "A customer came in today for a refill because her prescription was refilled wrong last night. She was given 5 times the prescribed dose for her child. I just wanted to make sure you were aware for follow-up because such an error could be potentially harmful to the child."

We all do make mistakes, which is why IMSP and other patient safety groups abound, with practical approaches to improving safety measure to prevent such errors. By saying something, you'll be helping to see this doesn't happen again. As a Eldridge Cleaver once said, "you're either a part of the solution or a part of the problem." We need more nurses to be part of the solution.

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Specializes in CTICU.
I'd stay out of it unless this guy makes a lot of errors. He knows he made an error. I'm sure he feels terrible about it. People make mistakes -- even people in the medical profession who know they need to be careful. Why do they make mistakes? Because they're incompetent, or because they're human? When you become a nurse you'll see how easy it is to screw up.

Reporting med errors is mostly to avoid them happening in future, not to punish someone or make them feel terrible. What if the next mistake kills someone? Would you be glad you "stayed out of it" then? I wouldn't. The point is, maybe there is a system problem that can be corrected in terms of things being entered incorrectly, or something like that.

It must be reported. You could say to the manager "I am not sure if you already know this, but I am a little concerned about something a customer told me last night" and mention about the person telling you they got the script filled wrong. That way you are not "tattling" on someone or accusing them of coverup, just bringing the issue to manager's attention.

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OP, nothing can be deleted off those systems...LOL. The script was entered and filled and made it across the counter. It has a permanent foot print so to speak. If management wants to investigate, they will be able to locate and find all activity related to this...

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What do you mean, "make it past 5"? I've been a nurse for three years now and, on my floor, we don't eavesdrop on other people's telephone conversations and report other people's medication errors. If that makes me a bad nurse, then so be it.

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Thanks for all the support! I mentioned something to the pharmacy manager tonight. I made it more from the customer service angle (like some of yall had said to do) and yay, he already knew, whew. I think the lady had already contacted him about it this morning. When I looked at her profile there is evidence though of the attempted cover up. :( I'm just so very thankful the mom never gave the med to her little girl. Sooooooo thankful!

What do you mean, "make it past 5"? I've been a nurse for three years now and, on my floor, we don't eavesdrop on other people's telephone conversations and report other people's medication errors. If that makes me a bad nurse, then so be it.

I was never eavesdropping on anyone's conversation. I really didn't know what had happened after his convo with her on the phone (except for who the person was on the phone and that they were on the phone for 30 minutes), I just knew people were acting shady. It wasn't until the next day until the lady came up there for her refund that I knew what happened. This was a life threatening error. I didn't feel the need to say something to get people in trouble. I felt the need to say something so this could be looked into so that measures could be put into place so this doesn't happen again. They are constantly putting more and more safety measures and updates into the pharmacy; something as simple as a conversion table by the computer could help to prevent this in the future.

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