Drug Topics - April 7, 2008 - (Page 3) 3 REDUCING YOUR RISK Ken Baker, B.S.Pharm., J.D. What will you learn from your mistake? he question is not whether you will make a mistake; the question is what you will learn from your error. There is a story told of a young executive with a large company. One day, he was sitting in his office knowing he was going to be fired. He had made a mistake which had cost his company $10 million. As he was wondering where he would go from that point in time, the president of the company summoned him to his office. The young executive timidly entered the office and for the next 20 minutes the president asked him several questions about the mistake. The president then told the young executive he could go back to his office. The young executive blurted out, “I thought you were going to fire me.” “No,” said the president, “we can’t afford to fire you – the company just invested $10 million in your education. Now, it’s up to you to show us what you have learned.” Over 80% of the professional liability claims filed against pharmacists and technicians allege that they have made a mechanical error. A mechanical error involves giving a patient the wrong drug or a label with the wrong directions or delivering a prescription to the wrong patient. I recall a claim coming across my desk a few years ago in which the patient, who had a prescription for digoxin, received warfarin in her bottle instead. The error was discovered a few days later when the pharmacy received a call from a hospital that the patient had been admitted after taking warfarin from her prescription bottle labeled as containing digoxin. When we investigated, we found that the mistake was made during filling. A pharmacist, while filling two prescriptions for different patients, had mixed up the two medications. One patient’s prescription was for warfarin 5 mg. The other patient’s prescription was for digoxin 0.125 mg. The warfarin was placed in the bottle labeled digoxin and vice versa. Both prescriptions, we were told, had been checked by a pharmacist. The digoxin/warfarin claim gives a good example for study. From our investigation, we learned valuable T This article does not constitute legal or consultative risk management advice. You should not rely on the information here for a plan of quality or for legal matters. Consult a risk management consultant or an attorney. lessons that could be applied to reducing (not eliminating) the risk of future prescription errors. One easy lesson was to fill one prescription at a time. We may congratulate ourselves on our ability to multi-task—do several things at one time—but multi-tasking prescriptions for different patients is usually a bad idea. New rule: No multi-tasking prescriptions. Two other mistakes were made in this case. One, the patient was not counseled. In this case the first patient had numerous prescriptions filled for digoxin, although this fill involved a newly written prescription. Counseling will be the subject of a future article in this series, so we will delay that discussion. The most critical problem uncovered in this case was that the pharmacist’s final check had missed catching the mistake. In order to fix this problem, we need a new procedure, one that takes into account the potential problems that could occur earlier in the prescription process. Our solution might then be to apply a checklist for the pharmacist’s final check used for each prescription. The checklist might look like the following: • Check label—right directions, right patient, right drug • Check drug—open cap and visually inspect the contents of the bottle • Check drug—Name on new Rx or on refill label against bottle used to fill Rx • Check drug—NDC check or scanner check • Check drug and directions—does the drug match the directions? • Check patient—right patient—no package mix-up? Memorize this checklist and practice it until it becomes a habit. Breaking a habit, good or bad, may mean “literally rewiring your brain.” We need to use such a checklist and “wire” our brain with a good habit. The question is not whether you will make a mistake; the question is what you will learn from the mistake. If the president described in the story above had fired the young executive, he might have made a second error – losing the one person who is most committed to learning a valuable lesson. References are available upon request. consults in the areas of pharmacy error reduction and risk management. He is an attorney, of counsel, with the Arizona law firm of Renaud Cook Drury Mesaros, PA. References for this article are available at kenbakerconsulting.com. THE AUTHOR http://kenbakerconsulting.com
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