My most serious pharmacy mistake

Dennis MillerThroughout 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.

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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.

Implications

Many of our customers are confused about the precise purpose of each pill they take. If this customer had taken the Halcion three times a day and subsequently had been involved in a car accident, my liability could have been astronomical, even if some part of the liability were apportioned to the physician whose error I had failed to catch.

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What if this customer had reported my mistake to the North Carolina board of pharmacy? Should I have been disciplined? Did I deserve to have my name published under “Disciplinary Actions” in the quarterly BOP newsletter, which is mailed to all pharmacists licensed in the state?

As much as I hate to admit it, I guess the argument could be made that I deserved a BOP reprimand. There were no extenuating circumstances that I can recall. I was working in a new store that was filling only about 50 prescriptions per day, so I can’t claim that understaffing was to blame.

The case could be made that when pharmacists exhibit extreme carelessness, humiliation before their peers through publication of their error in the pages of the BOP newsletter can serve as an urgently needed wake-up call.

What do you think? Should pharmacists’ names be published in instances of extreme carelessness?

What I think

We all agree that we need mechanisms in place to protect the public safety by weeding out extremely careless pharmacists. Yet many pharmacists are understandably reluctant to report their colleagues to their supervisors, because they realize that at any time the shoe may end up on the other foot.

In my situation, I feel that I punished myself enough through the ongoing self-doubt, self-recrimination, and self-loathing that I suffered. I honestly don’t feel that publishing my name and a description of my mistake in the BOP newsletter would have served any useful purpose in protecting the public safety or in causing me to be more careful.

What was your most serious dispensing error? Was it worse than mine? E-mail me (anonymously, if you want) and tell me about the Rx you wish you could do over again, the one forever seared into your brain.

Dennis Milleris a retired chain-store pharmacist living in Delray Beach, Fla. He welcomes feedback at dmiller1952@aol.com. His books "Chain Drug Stores are Dangerous" and "Pharmacy Exposed" are available at Amazon.com.