Pharmacy and Doctor Errors

[TrudyRN]

Another thread I was reading cites errors by pharmacists as being a frequent element in med errors and I knwo that pharmacists often enough dispense the wrong med, mislabel meds, including IV's (terrifyingly true), and so on.

What happens to them for making these errors? Nurses are crucified. What happens to pharmacists where you work?

Or to doctors whose poor handwriting or incorrect orders contribute to the problem?

[EmmaG, RN]

I know our pharmacist was worked to the bone. They are as stressed as we are by too much work to do in too little time without enough help. Our night shift pharmacist was told he HAD to work when he was soooo sick. Mycoplasma pneumonia, if I remember correctly. In any case, I and some others made his 'runs' for him, and did what we could do to help him out. When day shift came in the following morning, they found him out on the floor.

It's all in the bottom line, ya know.

[incublissRN, BSN, RN]

My hospital's pharmacy is horrible! Some errors that my coworkers and I have prevented could have been very scary. I don't know what happens to them when there is an error but I write them up every time.

[RNperdiem, RN]

In the past, nurses on my unit used to mix their own drips-Morphine, Fentanyl, Norepinepherine and insulin among others, and it used to make me very uneasy. It is so easy to make a med error that can have serious consequences.

Now, we must depend on the pharmacy to mix and deliver these infusions. There are many ICU's at my hospital. Luckily, the drips are delivered in a timely fashion. I sure hope they hired more pharmacists and pharmacy techs to handle the workload.

[nurse15dc]

Good question, Trudy RN. I know that if pharmacy makes a mistake and you then administer the incorrect drug, it becomes your mistake. Seems unfair but the nurse is liable because he/she is the final check.

Recently at my hospital a fellow RN discovered that the printed up a MAR with her pts name on it was really a list of another pts meds. The 2 pts were on similar meds except for a neuroleptic. When the RN caught the mistake she reported it and admitted that she had followed the wrong MAR and given the wrong meds the night before. Our NM said she was liable because she was the final safeguard and should have caught pharmacy's error.

Our pharmacy makes a lot of mistakes...wrong dosage, wrong drug, wrong route...hope we're able to catch them all before the med is given.

[perfectbluebuildings, BSN, RN]

I know our pharmacists are overworked. There aren't enough of them, especially at night, to handle the constant changing in orders on existing patients, and the multiple medications for each admission. Like the head pharmacist told us during orientation... "sometimes nurses and pharmacy have to work VERY hard at liking each other..."

The thing that really scares me sometimes about pharmacy is that once, I had a med labelled as what it should have been, but I could tell by the color that it was NOT the correct med (a liquid oral med). I know, it was only once, but what if it were a medicine that you couldn't distinguish that easily, but it was still labelled as the correct medication?

I am sure there are safeguards in place to prevent that and I know they are careful, and with all the hundreds of meds a day they prepare there are very few errors, but it still does scare me. I mean, we are all human.

I think I went a little off topic. I don't know what the consequences are for pharmacy errors; probably similar to our errors, whoever's responsible gets a "talking to" by their supervisor, or more intensive depending on the severity of the error.

As for doctors' handwriting... hmmm... no idea. (Most of ours are actually good... just a few notorious ones..)

[Elvish, BSN, DNP, RN, NP]

I don't know the answer to that question at my facility, but it is worth finding out. I will bring it up to my supe at work tonight.

[bigsyis]

We had a Pharmacist who made fairly frequent errors, but he was a NICE guy and always immediately corrected anything that was brought to his attention. One day at work I noticed that he hadn't been at work in a few days, and asked about him. I was told that he was no longer employed there. He had been the Director of our Pharmacy! The Pharm Tech I asked said that she couldn't talk about it, but to check the Pharmacy Licensing page on the Internet for our State Dept of Professional Regulation. I was busy, and didn't. I heard later that he had lost his license secondary to errors made while under the influence of ETOH! I do know when I was a Charge Nurse that he had scheduled Morphine for a pt q4h plus, had recorded it as a PRN order, as well. Fortunately the nurse discovered it and brought it to me before she medicated the pt.