This patient's birthday was the happiest day of her life. But that's only half the reason the hospital pharmacist has never forgotten her.
Several years ago, the head of my hospital’s medical record department was performing an audit. She met with me about Mrs. C., a woman who had died of pancreatic cancer. She wanted to know the cost of a medication that Mrs. C. was receiving. I told her and asked whether she would also like the price of another drug.
She stated that she didn’t need the price of that drug, because Mrs. C. had never received it. She thanked me and left the department.
Mrs. C. was on a monthly regimen; she was supposed to receive the same medication every month. For nine out of 10 months, she received the same medication that the medical record department was inquiring about. However, in the fourth month of her therapy, on March 21, she received the wrong drug.
I knew that accidental administration of this drug, rather than the one prescribed, would not kill her. However, it was a medication error.
I considered my options. I could keep quiet and say nothing. Mrs. C. had not died from taking the wrong drug; she died as a result of complications of pancreatic cancer. Furthermore, reporting the error would create excessive paperwork, a great deal of aggravation, and heartache for those directly involved. I decided to say nothing.
A just culture
Many hospitals claim they have a nonpunitive policy when it comes to medication errors. Hospitals want to know about unsafe practices in an attempt to prevent future problems. They encourage their staffs to report these situations without fear of retribution. The goal is to correct behaviors rather than punish.
These facilities review medication errors and near misses. They follow strict guidelines to first evaluate the caregiver’s action in order to determine if it was a system error. If the caregiver's action is deemed malicious or if the caregiver makes repeated mistakes, only then is punitive action taken. This process is known as “just culture.”
Several months later, my boss called me to his office to show me a letter from Mrs. C.’s daughter. Her daughter stated,
Mom looked forward to her monthly visits to the suite. Her biggest thrill was the birthday party that you gave her.
It made Mom feel wonderful.
It was perhaps the only time that we left the Chemo Suite and went shopping instead of going home.
I told Mom that she should go home and rest like she usually did. But no, she stated that she felt well enough to go
shopping that day.
This is how Mrs. C should be remembered. Not as a medication error statistic, not as one who might be responsible for people losing their job, but as an individual who touched everyone she encountered. She should be remembered for the stories she told, not for the root causes and algorithms that would have to be generated. She should be remembered for her smile and her caring, not for the miles of endless paperwork that someone would be forced to prepare. She should be remembered for the happiness she took from the party that we gave her. That was how she should be remembered.
I reread the letter, and there it was.
Mrs. C. had a tough bout with pancreatic cancer. She was a brave woman, but after a treatment day, things were difficult.
After receiving her treatment, Mrs. C would go home, throw up, and collapse. She wouldn’t eat for 24 hours. She’d be groggy, headachy, and in pain. This happened every treatment day. Except for one.
On that day, after treatment, we celebrated her birthday, and Mrs. C. insisted on going shopping with her daughter. She said she felt wonderful, the best she’d ever felt.
Staff members had their own reasons to remember Mrs. C’s birthday. I’ll remember it, as well. Because the best day of her life, ironically, was the day that she got the wrong medication. It was the day of the medication error. Her birthday.
Daniel Shifrin is a career service rep and pharmacy tech instructor in New Jersey. Contact him at email@example.com.