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    Pharmacists write in: Worst mistakes, Part 1

    Dennis MillerDennis MillerI received a lot of interesting feedback from my recent three-part series on pharmacy mistakes: “My most serious pharmacy mistake” (July 1), “Who is to blame for pharmacy mistakes?” (July 22),and “State BOPs and public safety” (August 5).

    One pharmacist wrote to me, “Getting a pharmacist to admit an error is like trying to get a woman who has had an abortion to talk about it. It is not going to happen.”

    Apparently many pharmacists disagree, seeing significant educational value in discussing their errors. Typical of these, another pharmacist wrote, “Thanks for sharing your experience. I think hearing about other people's mistakes is a great way to hopefully prevent them from happening again.” 

    With that thought in mind, I am sharing a small sampling of the e-mail I have received.

    See also: "My most serious pharmacy mistake"

    Real-world pharmacist errors

    Pharmacist #1:  “My biggest error was dispensing terfenadine (Seldane) to a patient on quinidine. I contacted the cardiologist but he said that's what he wanted, so I dispensed it. The patient ended up dying of sudden cardiac arrest a few months later.”

    Pharmacist #2:  “I made a mistake which will forever haunt me. U-500 insulin, gave 350 units rather than the desired 70 units. Sent the patient to the ICU overnight (recovered fine). Inexplicable! I knew the insulin, knew the risks, I completely knew better, and still made this damned mistake! Still makes me feel so stupid every time I touch ANY insulin. Probably a good reminder, but it still hurts, years later.”

    Pharmacist #3:  “I guess I should be taken to the whipping post too. My worst error was when I was an intern (40 years ago). Gentamycin dose of 39 mg. Didn't catch that it was for an infant. No harm done, but I never forgot it.”

    See also: Who is to blame for pharmacy mistakes?

    Pharmacist #4:  “In 2008 I filled a triplicate Rx for morphine ER 200 mg TID. The Rx was an original from a pain specialist who had been treating our mutual patient, an elderly female, with hydrocodone/apap 10/325 TID plus an Rx for carisoprodol.

    “Knowing the patient and the doctor, I filled it. It was in his handwriting on a triplicate form. Thinking she had taken a turn for the worse, I did not question it.

    “She took one dose and ended up in the ER. After she was released from the ER, she immediately contacted a lawyer and tried to sue my pharmacy and the MD.

    “I ended up paying for her ambulance ride to the ER and a fine from the board of pharmacy. The pain specialist who wrote the rx suffered no repercussions.

    “At the time I was afraid to question the all-powerful pain specialist. How dare I question his prescriptions!

    “Should I have been disciplined? Now I would say yes. Should the MD who wrote it have been cited? I think if I was in error, he was complicit in that error.”

    Pharmacist #5:  “I was in my first or second year out of school, working in a 250-bed hospital. A nurse came to the pharmacy, wanting floor stock heparin flush.
    “I went to the heparin shelf, not knowing what I was doing, and selected a box of 5000 unit heparin, not flush. At the time, I didn't even know that there was a difference in heparin to flush a line and heparin to anticoagulate. I handed it to the nurse without a thought.

    “It turned out the nurses flushed with the full strength heparin that I dispensed and they had to do heroic reversal of the life-threatening thin blood it caused one patient.

    “At every pharmacy where I have worked since then, I have separated the heparin flush from the regular heparin and put a big sign by the regular heparin that said, ‘NOT FOR FLUSH.’”

    Dennis Miller, RPh
    Dennis Miller is a retired chain-store pharmacist living in Delray Beach, Fla. He welcomes feedback at [email protected] His books ...

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