Drug Topics - November 3, 2008 - (Page 3) www.drugtopics.com DRUG TOPICS 3 MEDICATION ERRORS Ken Baker, B.S. Pharm., J.D. What to do when you make an error: First, take care of your patient L ast month we looked at some things you should not do in the event of a medication error. While we said you may apologize after an obvious error, you should not pay money, make commitments, or admit liability. Admitting liability for an error, we said, is not the same as admitting you made a mistake. In this issue, we will discuss your most-important duty when an error is made. Luckily, the test for most of us is not perfection, but how well we react when confronted by a mistake. The importance of this discussion may be not the advice, but the fact that it leads pharmacists and technicians to consider what they will do before an error occurs. A plan works better than a reaction. Usually, the first notice we get of a potential error is a phone call from a patient or a physician. When it is from the patient, the conversation may begin with, “This tablet looks different.” This is a Pharmacists Only Question. By that I mean, no matter who answers the telephone, that question is referred to only a limited number of staff who have been trained to deal with it. In addition to pharmacists, it may be an experienced, trained technician, but it is not “whoever answers the telephone.” We reviewed 100 consecutive claims a few years ago at Pharmacists Mutual. Of those 100 claims, eight occurred despite the pharmacy having been warned that the prescriptions may have contained an error. All eight of these claims could have been avoided if the question “are you sure these are right” had been properly investigated. Someone at the most of those pharmacies had said, we believe without checking, “Oh, it is just a generic, go ahead and take it.” When a call indicating an error is received, the one handling the call should assume that an error was made. This assumption should remain until it is proven otherwise. Train each member of the staff that a call regarding an error is a Pharmacists Only Call and instruct then how to initially handle such a call and to whom they can refer it. The pharmacists who are authorized to handle a potential error call should also be trained. If, after an investigation, it is determined that there was an error, the priority should shift to the patient. If the patient took any of the medication, the prescriber must be contacted and informed, if he or she is not already aware. Depending on the medication and the patient, the pharmacist may decide to suggest an emergency room visit. If so, be certain the patient has the emergency room staff call the pharmacy for information. [See the discussion of Med Pay insurance coverage in last month’s issue.] Whether the patient took the erronous medication or not, the pharmacist should be sure the drug is removed to prevent anyone from inadvertantly taking it in the future. Whether the patient took the erronous medication or not, the pharmacist should be sure the drug is removed to prevent anyone from inadvertantly taking it in the future. The pharmacist will usually want to pick up the incorrect prescription. When it is returned to the pharmacy, do not destroy it, but place it in a secure place until you are sure there will be no claim or Board of Pharmacy complaint. Preserving the prescription will show there was no attempt to hide what happened. If the patient refuses to give the prescription to the pharmacy, ask them to seal it in an envelope, place it in a safe area, and destroy it or return it to the pharmacy when it is no longer required. When we make an error, the first and most important step in risk management should be to care for our patient. That is the compassionate thing to do; that is the professional thing to do; and that is the smart thing to do. 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. Ken Baker is a pharmacist and an attorney. Mr. Baker 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. http://www.drugtopics.com
Table of Contents Feed for the Digital Edition of Drug Topics - November 3, 2008 Drug Topics - November 3, 2008 Medication Errors: What to do When You Make a Mistake Stockholm Oncology Congress Reports on Several Studies Drug Topics - November 3, 2008 Drug Topics - November 3, 2008 - Drug Topics - November 3, 2008 (Page 1) Drug Topics - November 3, 2008 - Drug Topics - November 3, 2008 (Page 2) Drug Topics - November 3, 2008 - Medication Errors: What to do When You Make a Mistake (Page 3) Drug Topics - November 3, 2008 - Stockholm Oncology Congress Reports on Several Studies (Page 4) Drug Topics - November 3, 2008 - Stockholm Oncology Congress Reports on Several Studies (Page 5) Drug Topics - November 3, 2008 - Stockholm Oncology Congress Reports on Several Studies (Page 6)
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