Medication/Pharmacy errors...

[ObtundedRN]

So working in the hospital, as a nurse, one of our responsibilities is to be the very last check that a medication is appropriate and safe for the patient. I catch pharmacy errors on a regular (and too frequent) basis. Usually it is simple mistakes, caused by any number of contributing factors. But sometimes I find big errors, such as pharmacy putting 3 runs of IV KCL on the wrong patient's eMAR, who happens to have a K of 5.1!

So if I find these errors in the hospital, it makes me question how often they happen outside of the hospital, where there is no nurse to help verify that the medication is correct.

Today, one of these errors happened to my newborn nephew. The retail pharmacy entered the wrong dosage on the label... 5 times the intended dose. This dose was fortunately still a safe dose, even for a newborn. So luckily the MD says there should be no cause for concern. But just the fact that this kind of error occured and for a newborn that isn't even a month old yet, is scary.

So please, everyone make sure you're verifing not only your patient's medications against the original MD order, but also make sure you and your family are getting the correct meds and doses from your own retail pharmacy.

[brillohead, ADN, RN]

And another thing, to say your med was intentionally filled wrong is just plain ignorant..(sigh)

I don't see where anyone said this.

"They only appologized because they got caught"

That's NOT the same as saying it was done intentionally.... all they were saying is that the pharmacy employees in question didn't really give a rat's patootie -- they didn't do it on purpose (intentionally), but they didn't really care about their error either. The employees did the required "apologize to make the customer happy" motions without actually feeling apologetic. Like when you tell a 5yo to apologize for hitting his 3yo sibling and he says, "I'm sorry, okay!!!!" He's just going thru the motions of saying he's sorry w/o really meaning it.

[ckh23, BSN, RN]

"They only appologized because they got caught"

I took that to mean because they made an error, not because they intentionally filled it wrong

[Jackfackmasta, ASN, RN]

I am a pharmacy tech and have been one for almost 7 years. It is not our responsibility to check the medication before it leaves the pharmacy, thats why the pharmacist makes the big bucks! We fill what they verify, then they verify it again before it leaves. Anywhere you have people who have to make any decisions there are going to be errors. That's why we are human. Just like nurses, and doctors who make errors. I have found errors my pharmacist made before giving the med to the patient, but like I said they are human. It is best to check meds when you get them bc some are def gonna slip through now and then. I can honestly say that in the time I have worked in the pharmacy there were never any huge, harmful mistakes thank God. That doesn't mean they don't happen.

"People who make mistakes are people who do things." Author unknown.

I diasgree that "It is not our responsibility to check the medication before it leaves the pharmacy, that's why the pharmacist makes the big bucks!" It is the responsibility of EVERYONE who is in contact with that medication to check it. Everything is centered around the pt and safety and putting the responsibility on just the pharmacist is irresponsible even if they make big bucks. The more hands that med touches and is checked the higher the chances a error is caught and that NICU baby doesn't die because someone chose to be irresponsible and not check the medication because the pharmacist makes big money. Errors happen and EVERYONE in contact with medication is responsible to make sure it does not reach the pt who does not have control over it.

[Butterfly0328]

Not sure where this responsibility lies, but my roomate takes 20mg of Inderal q12h and when her doctor gave her a new rx it was apparently written out for 60mg q12h. The pharmacy filled it, the exact same pharmacy that has been filling it for 10+ years, and we brought it home thinking it was the 20mg. Thank goodness checking every script for errors is something we have always done and this was noticed right away. I was a little surprised the pharmacist didn't question the huge increase in dosage especially since it's a beta blocker. I guess the bottom line is to always check the dosage etc when we get maint. meds , but if it's a new rx all we can do is pray it's for the correct dosage. Super scary stuff.

[MrChicagoRN, RN]

Merlee,

It's odd that they said you didn't have to fill out an incident report - an error occured, not by you, but by another staff member, you were just smart enough to have noticed.

Incident reports should be used to identify trends & potential risks, not just record mistakes that have reached the patient.

Institutions vary regarding "near misses," but it appears that this one was close enough that it should have been documented.

[jbluehorseh]

I am a pharmacy tech and have been one for almost 7 years. It is not our responsibility to check the medication before it leaves the pharmacy, thats why the pharmacist makes the big bucks! We fill what they verify, then they verify it again before it leaves. Anywhere you have people who have to make any decisions there are going to be errors. That's why we are human. Just like nurses, and doctors who make errors. I have found errors my pharmacist made before giving the med to the patient, but like I said they are human. It is best to check meds when you get them bc some are def gonna slip through now and then. I can honestly say that in the time I have worked in the pharmacy there were never any huge, harmful mistakes thank God. That doesn't mean they don't happen.

"People who make mistakes are people who do things." Author unknown.

The first line of safety starts with you, don't put if off on someone else

[Esme12, ASN, BSN, RN]

i am a pharmacy tech and have been one for almost 7 years. it is not our responsibility to check the medication before it leaves the pharmacy, thats why the pharmacist makes the big bucks! we fill what they verify, then they verify it again before it leaves. anywhere you have people who have to make any decisions there are going to be errors. that's why we are human. just like nurses, and doctors who make errors. i have found errors my pharmacist made before giving the med to the patient, but like i said they are human. it is best to check meds when you get them bc some are def gonna slip through now and then. i can honestly say that in the time i have worked in the pharmacy there were never any huge, harmful mistakes thank god. that doesn't mean they don't happen.

"people who make mistakes are people who do things." author unknown.

really? everbody makes mistakes? you're just human? i've got news for you....

nurses aren't considered human and we aren't allowed to make mistakes. read the following....

the suicide of a nurse who accidentally gave an infant a fatal overdose last year at seattle children's hospital has closed an investigation but opened wounds for her friends and family members, as they struggle to comprehend a second tragedy.

kimberly hiatt, 50, a longtime critical-care nurse at children's, took her own life april 3. as a result, the state's nursing commission last week closed its investigation of her actions in the sept. 19 death of kaia zautner, a critically ill infant who died in part from complications from an overdose of calcium chloride.

after the infant's death, the hospital put hiatt on administrative leave and soon dismissed her. in the months following, she battled to keep her nursing license in the hopes of continuing the work she loved, despite having made the deadly mistake, friends and family members said.

to satisfy state disciplinary authorities, she agreed to pay a fine and to undergo a four-year probationary period during which she would be supervised at any future nursing job when she gave medication, along with other conditions, said sharon crum of issaquah, hiatt's mother.

"she absolutely adored her job" at children's, where she had worked for about 27 years, said crum. "it broke her heart when she was dismissed ... she cried for two solid weeks. not just that she lost her job, but that she lost a child."

continued: http://seattletimes.nwsource.com/htm..._nurse21m.html

as hospitals rely more on electronic data, worries over potential errors grow

the medical error that killed genesis burkett began with the kind of mistake people often make when filling out electronic forms: a pharmacy technician unwittingly typed the wrong information into a field on a screen.

because of the mix-up, an automated machine at advocate lutheran general hospital prepared an intravenous solution containing a massive overdose of sodium chloride-more than 60 times the amount ordered by a physician.

when the nutritional fluids were administered to genesis, a tiny baby born 16 weeks prematurely, the infant's heart stopped, and he died, leaving behind parents stunned by grief.

although a series of other errors contributed to the tragedy, its origin-a piece of data entered inaccurately into a computer program-throws a spotlight on safety risks associated with medicine's advance into the information age, a trend being pushed aggressively under health reform.

the federal government is aiding the shift with $23 billion in incentives to medical providers who buy electronic medical records or computerized systems that automate drug orders and other medical processes. the hope is that these technologies will enhance access to vast amounts of information tucked away in paper files and meaningfully improve medical care....

http://www.latimes.com/health/ct-met-technology-errors-20110627,0,2158183.story

you are wrong.............and as a nursing student you will find out how wrong you really are. it is everyone responsibility to check every med, everytime you come in contact with the meds themselves.

all nurses know that it isn't a med error until the nurse gives it. in the second story.....the pharm tech made an "unwitting mistake" while the nurse in the first story made a "fatal error"............it's a big deal....a real big deal!

[Gold_SJ]

I feel rather strongly on this issue. In our facility the rules are suppose to be ZERO TOLERANCE and any error, non signing, unreadable handwriting ect. Has to be refused by the nurse and rewritten by the doctor. (here everything is hand written not computerised).

Being in paeds you have to constantly be checking the dosages by the child's weight and ensuring the order is right. But repetively the orders are wrong, over or underdosing so your'e forever ringing up and harrassing doctors. See the children come through emergency and the doctors there are uncomfortable/less use to prescribing for children so the doses often are wrong easily 60% when it comes to antibiotics, nothing particulary dangerous but still not the optimal dosage.

And I'm not even going to get started on having children arrive with everything writing on an adult medication chart instead of a pead. (Weights aren't recorded in the adult charts)

Pretty much anyone who goes through that exhaustion of chasing up medical officers day in and out. I send you my compassion, its a big job and frustrating when it comes down to another just not taking the time to check in a resource book.

So your comment does make me wonder what occurs out in the community. If in the acute system that many errors take place, what about out there? The pharmacists would be doing the task of the nurses I'm assuming, its pretty lucky humans are so resiliant ^.~

When it comes to meds, double and triple checking is the best method to go by. Its so easy for something to slip past otherwise. And like the tragic stories about it's certainly too late to undo.

I have a question though, here in Australia nurses double check all additives, IV medications, IM medications and antibiotics in a pair before giving. Does this happen in other countries also?

[xtxrn, ASN, RN]

So working in the hospital, as a nurse, one of our responsibilities is to be the very last check that a medication is appropriate and safe for the patient. I catch pharmacy errors on a regular (and too frequent) basis. Usually it is simple mistakes, caused by any number of contributing factors. But sometimes I find big errors, such as pharmacy putting 3 runs of IV KCL on the wrong patient's eMAR, who happens to have a K of 5.1!

So if I find these errors in the hospital, it makes me question how often they happen outside of the hospital, where there is no nurse to help verify that the medication is correct.

Today, one of these errors happened to my newborn nephew. The retail pharmacy entered the wrong dosage on the label... 5 times the intended dose. This dose was fortunately still a safe dose, even for a newborn. So luckily the MD says there should be no cause for concern. But just the fact that this kind of error occured and for a newborn that isn't even a month old yet, is scary.

So please, everyone make sure you're verifing not only your patient's medications against the original MD order, but also make sure you and your family are getting the correct meds and doses from your own retail pharmacy.

After my dad had a lap appy, I went to go get his pain meds. It was a drive-thru window, and the kid asked me dad's name and address, while looking at the bag/label. He told me the co-pay, which was not what dad had said. I pulled away from the window to check the med- it was for someone with the same name, a TOTALLY different address, and for asthma meds... I pulled back into line, and got up to the window and told the kid I got the wrong med. He had to get the manager (a pharmacist). My uncle almost went to get the meds- but I ended up going for some reason I don't remember (I was on home health at that time, and not supposed to be away from home, let alone running errands). Had I NOT gone, dad would have been breathing great, hurting a lot, and probably running around like a chicken on speed (he's not one to sit still on a good day...). His brother, and friend who had been alternating "dad watch" wouldn't have known the med wasn't for pain. Why would they? :)

I've gotten ER tabs instead of regular release.

[iluvivt, BSN, RN]

I read a story last year that Walgreens make the most mistakes. I could not remember the percentage but I remember thinking it was a lot. I never trust anything...I check everything and I never ever administer a medication that I do not all about, including the dosage. Also if you know your patients and their medical hx yo can catch errors a bit easier..if the medication does make sense based on what you know about a patient..then question it?

[rita359]

Human beings make mistakes every day. Fortunately, individuals do not always make mistakes but sometime they do. Mistakes are not intentional but , realizing mistakes can be made, it is best to check and recheck.

[psu_213, BSN, RN]

"They only appologized because they got caught"

That does not mean they did it on purpose. I just means that the person who posted this suggested that they were not really sorry that they messed up. Quite a difference.