Drug Topics - September 1, 2008 - (Page 4) 4 DRUG TOPICS Sept. 1, 2008 www.drugtopics.com Reducing Your Risk the patient to be sure to remove the old patch before applying the new one, in order to avoid an overdose. It was the next day before the patient called back to say the directions were wrong. She knew she should apply one patch only every seven days, so the error had not caused any harm, except for angering the customer. What should Julie do to be sure that the risk of a similar error is not repeated? What would you do? An error is a mistake that gets though the prescription workflow and reaches the patient. The fact that a patient was not harmed or did not take the incorrect prescription is irrelevant to the learning process. The error is a signal that something is wrong. The analysis of the error should go behind the simple facts to uncover the vulnerabilities disclosed by the mistake. The lesson must go beyond the next prescription for Catapres tts-1. The analysis may look like the one to the right. This analysis is only an outline with many blanks. I invite the reader to fill in the specifics in each area more completely. If this error happened in your pharmacy, what would the analysis look like? Since we do not know, and sometimes you will not know, exactly what happened in the actual incident, consider what could have happened. Following the next medication error in your pharmacy, use a similar analyses system as a learning tool. The more people involved, the more will be learned and the less likely that the next error will occur. After this analysis, use the findings to suggest solutions. The goal is to make the next error less likely. One final note of caution in the area of “who.” Quality programming must be a blame-free system, or it will eventually fail. Do not just blame an individual. The “who” is not the individual person, unless it discloses one who needs special training. “Who” includes the circumstances in which the mistake was made. In most cases the mistake is one that any of us could make were we in the same position. If we start blaming the individual, we miss the real and important lessons. KEN BAKER is a pharmacist and an attorney. He practices law as an attorney, of counsel, with the Arizona law firm of Renaud Cook Drury Mesaros PA. He also consults in the areas of pharmacy error reduction and risk management. For questions or citation and footnotes, contact Ken Baker at ken@kenbakerconsulting.com. Problem: 1. Directions entered incorrectly into the computer 2. Mistake in label directions not caught before reaching patient 3. The computer software did not catch the mistake, or did it? What happened? • Technician misread pharmacist’s writing on prescription, or • Technician decided “every seven days” was wrong and changed to “every day” without checking with the pharmacist, or • Technician used an incorrect SIG Code, such as “qd,” or • Something else? (What about the pharmacist and the other technician?) Where? (for each, fill in the specifics) • Computer data-entry station, and • Prescription-filling area (did not catch mistake), and • Pharmacist's final-check area (did not review label), and • Pharmacist counseling area (did not perform show and tell), and • Pharmacist counseling area (did not make sure the patient knew fully how to use the patch). What if the patient had not caught the mistake? When? (for each, fill in the specifics) • When entered? • When filled? • When counseled? • When checked? Who? (for each, fill in the specifics) • Entering technician • Filling technician • Counseling pharmacist • Checking pharmacist • Patient Environment (for each, fill in the specifics) • Noise • Clutter • Counseling area conducive to a private (HIPAA) session with the patient? This article does not constitute legal or consultative risk management advice. You should not rely on the information here or in any similar article for a plan of quality or for legal matters. Consult a risk management consultant or an attorney. This example is based upon an actual error, but the names, locations, and some of the specifics have been added or changed for purposes of the example. The purpose of the example is to instruct, not to report an event, so I have taken liberties. http://www.drugtopics.com
Table of Contents Feed for the Digital Edition of Drug Topics - September 1, 2008 Drug Topics - September 1, 2008 Analysis of a Medication Error Pilot Program Urges Safe Disposal of Medications Drug Topics - September 1, 2008 Drug Topics - September 1, 2008 - Drug Topics - September 1, 2008 (Page 1) Drug Topics - September 1, 2008 - Drug Topics - September 1, 2008 (Page 2) Drug Topics - September 1, 2008 - Analysis of a Medication Error (Page 3) Drug Topics - September 1, 2008 - Analysis of a Medication Error (Page 4) Drug Topics - September 1, 2008 - Pilot Program Urges Safe Disposal of Medications (Page 5)
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