Throughout my career, which took place mostly in North Carolina, I had a great fear of opening the state Board of Pharmacy’s quarterly newsletter and seeing my name connected with a reprimand for a pharmacy mistake. That never happened. I did make a few mistakes, though, none of which were reported to the BOP as far as I know.
The big one
My most serious mistake occurred when I typed “Take one tablet 3 times a day” on a Halcion (triazolam) prescription soon after that drug arrived on the market. Actually, what happened is that the prescribing physician mistakenly but clearly wrote TID (three times a day) on a handwritten prescription, and I didn’t catch his error.
I am ashamed to admit that I dispensed this drug without actually knowing — or taking the time to find out — what the new drug was used for. Of course, all pharmacists now know that Halcion is a sleeping pill taken once a day, usually at bedtime.
The customer evidently told his physician about the error, because the physician called me, asking, “Why would you put ‘three times a day’ on a sleeping pill?”
I said, “Can you hold on just a second while I pull the prescription from our files?” When I retrieved the hard copy, I immediately saw what had happened. I told him, “I have your prescription here in my hand. You clearly wrote TID. I can fax you the prescription if you would like to see it.”
The physician accepted my word that he had mistakenly written TID, and he did not ask for a fax of the prescription.
Basically, the physician made an error and I failed to catch it. We both screwed up, so we were equally responsible. Thankfully, the customer was not harmed in any way, as far as I knew. And thankfully, there were no further repercussions. But if the customer had actually taken the drug three times a day, per the instruction I typed on the label, this could have been disastrous.