3. Called-in Refills
Refilled a called-in request. Patient just left a message and asked to refill the last HIV medication they had on file. Next day refilled and sent it to the patient, not knowing that the last refilled medication was discontinued and a new medication was called in.
By the time I tried to contact the patient, she had already taken the medication and was having adverse reactions to it. I finally got in contact with her, letting her know she had to discontinue the medication that was sent and start on the new medication.
In order to fix the mistake I needed to call her doctor and inform him that she had taken the discontinued medication. I had to notify the Board of Pharmacy of the error. I also used this as a teaching tool for the technicians when they retrieve a voice mail request to verify with the patient to see exactly what they need refilled.
Missed 50% dextrose on the tpn auto fill for 46 neonates. The error was caught before any babies got infusion. I went to an inpatient mental health unit for 2 weeks and did not go back to work full time for a few years. Then went to work at poison control center for 2 years, then a PBM for last 17 years. So, I got out of the trenches.
Miscalculated a pediatric dilution as a new graduate pharmacist and gave 10 times the dose. I learned that I needed to complete an "independent second (or confirmatory calculation)" of all extemporaneous compounds prior to mixing and/or checking product.
Do not rely on what the preparer says they did. Do not give into peer pressure or ego that this is stat or sounds correct—ask for a double check. I ask this question in each interview for techs and pharmacists.