Accepting Responsibility

You know.. no one is perfect. Like the bad apples analogy I posted a while back, we all have varying degrees of imperfections. That's why the corporations are building robots to replace us. But, the key is to acknowledge our imperfections and not allow them to get the best of us.

If you've been a pharmacist for a while, then you'll know that there are many good pharmacists, who for whatever reasons, fall victim to their impulses and cross over that fine line between right and wrong, ethical and unethical. And that's okay. Any rational person realizes that we can't always be perfect in our behaviors. Sometimes we're gonna slip.

But, it's also important to understand that whenever we screw up, we need to own up to our mistakes. As long as they're not done to intentionally harm someone, most everyone can empathize with our faults and mistakes if we accept responsibility for them and do our best not to let them happen again.

It's only when we deny our mistakes, cover them up, and try to fight "the man" when the shit hits the fan and the consequences become severe. So, if there's anything I'd like my readers to embrace, it would be to be honest, accept responsibility, and to recognize where the fault actually lies.

Error Prevention In The Lab

How many times have you been thrown to the wolves at work, without adequate training, and found yourself having to learn the hard way or having to suffer the consequences?

I've had plenty of jobs where I was given the bare minimum of training or orientation, left to fend on my own, and then was criticized, punished, or held personally liable if I did something wrong, even though I wasn't properly-trained, informed, or made aware of certain policies or procedures beforehand. I often refer to it as "being set up for failure".

Unfortunately, sometimes the consequences of this apathy towards error prevention can be tragic.


Source: Landmark worker death case continues against UCLA chemistry professor

A Scary Medication Misadventure

Did you know that over one-million people each year are harmed by medication errors? This is why it is imperative that you must personally become involved in your own, and your children's, health care. Please don't ever assume that a mistake cannot happen to you. They occur more easily than you might imagine. But you can personally help prevent these errors from harming you or your loved ones.

Ask your doctor to explain the prescription to you, and understand it before you leave his/her office. When picking up your prescription at the pharmacy, please double-check and question everything about it before you leave. Make sure you aren't getting someone else's prescription - double-check your name, address, the medication name, what it's used for, how it's to be taken.

Most importantly, always make sure to discuss it with the pharmacist, not the cashier or a pharmacy technician. Many errors can be prevented by performing these few simple steps.

Pill Date

Be careful out there. Talk to your pharmacist, know your pills.


Pill Date - a commercial for pharmaceutical from Meissa Hampton on Vimeo.

Where's The Safest Hospital Located?

Nope, it's not Johns Hopkins in Baltimore, it's also not the Mayo Clinic located in Rochester, nor Massachusetts General Hospital in Boston. It's not even considered one of the top fifty hospitals in the country. According to U.S. News & World Report, it's not even the number-one ranked hospital in it's own home State.

The safest hospital in America is Denver Health Medical Center, located in the great State of Colorado. According to a June 30th PBS NewsHour report, it has the lowest mortality rate of any academic medical center in the U.S., and sets the bar for patient safety.

Preventing The Perfect Rx Storm

Pharmacists, doctors, and patients need to work in tandem to help prevent the perfect storm from forming, which could lead to a continuing medication error.

ABC-15 News in Phoenix reports on a recent prescription error in which a patient received 50 mcg of liothyronine instead of the prescribed 5 mcg dose. The unfortunate young lady in this incident continued taking the misfill for months, and experienced all of the adverse effects one would expect from receiving 10 times the prescribed dose of her thyroid medication.


The perfect storm in which I'm referring happens when all of the following occur together -

1. A prescription order is entered incorrectly and a prospective DUR fails to catch it.
2. The pharmacist doesn't counsel the patient at the time of dispensing a new prescription.
3. The patient doesn't take the initiative to speak up to prevent errors.
4. The provider doesn't review the patient's prescription medications with each visit.

Of course, I don't know all of the sources that led to this error, and while not attempting to assess cause or blame, it seems to me that all four of these contributing factors occurred in order of succession, which may have allowed this incident to continue for so long. Any interruption in that perfect storm may have prevented the error from happening or continuing.

According to the video, the Arizona Board of Pharmacy is still investigating this incident. If you'd like to know the results of the investigation, who was involved, including any possible disciplinary actions, the board posts their meeting notices and meeting minutes online.

A Drug By Any Other Name

While I write this blog for myself and other pharmacists, I realize that many non-pharmacists read it too. So, I like to include posts to help the public understand why things happen behind the counter, to help them understand how medication errors may happen, or how to help prevent medication errors themselves.

One of the questions that I've heard from upset patients before is, "how the hell did the pharmacist mix up two drugs that are completely different, and don't even sound the same"? As I've described previously, piss-poor handwriting can easily lead to dispensing errors.

From Susan Proulx, PharmD at Med-ERRS, here's how easily it can happen -


Lipitor or Zyrtec? How a doctor's bad handwriting can change your prescription from Marketplace on Vimeo.

Speak Up To Prevent Errors

I think I speak for all healthcare providers when I say, "help us help you".

We are not infallible. I've never met any healthcare professional who would intentionally try to harm one of their patients, it's devastating on both ends. But as much as we try to prevent them, mistakes can happen. You can help us prevent them.

Please become an active participant your own health care and learn to question everything that's being done to help you. When your doctor or other healthcare provider gives you a prescription, politely hand it back and ask that provider to read it to you.

This one simple step will allow that provider to double-check what was written, and will keep you from having decipher and understand his or her form of ancient Sanskrit handwriting.

This will also help prevent errors or delay at the pharmacy, as you can quickly tell the pharmacist what the doctor prescribed in case the pharmacist can't read it either.

This same simple step should also be applied when picking up your prescription at the pharmacy. If the pharmacist hasn't already done so, politely hand the bottle back to the pharmacist, and ask him/her to "Show and Tell". They know what that means.

The pharmacist should open the bottle, show you the medication, and read the whole prescription label to you. Doing so will allow the pharmacist another chance to catch any errors. It should also match what the doctor told you. If not - Speak Up!