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    The red pen rules: How to prevent pharmacy error

    Peter A. Kreckel, RPhI come from a family of hard-working, hands-on men. My brother Don is a welder. One of his favorite expressions is "dung runs downhill" (okay, Don uses another word). I think of this often, because essentially, the guy in the white coat is at the end of the pipe. 

    Irate customers, unhappy docs, and pharmacy staff all expect the pharmacist to be the final authority. As a teacher and preceptor, I have observed that a lot of students don't seem to be ready for this responsibility, not to mention the ultimate job of the pharmacist: to make sure that the right medication goes to the right patient. If this fails, your ability to recite Micromedex from memory is of no value.

    Our ultimate charge is to get the right medication to the right patient, and to give that patient the educational information needed to support the most positive outcome.


    I interact with a lot of student pharmacists, and I like to bounce ideas off their heads. One student pharmacist, Sophia, is in her last rotation from Pitt. She is bright, energetic, and full of anticipation about her professional future. When I asked her what she would like to see in this article, she asked me to address the concept of "hand-holding."

    Hand holding concerns students who about to graduate and are afraid to make decisions. In the community pharmacy environment, these decisions would pertain specifically to checking an Rx, dispensing it, and "letting go."

    While they were students, young pharmacists-to-be had their hands held, meaning that they had no ultimate responsibility. Now, as newly fledged pharmacists, they are the ones at the end of the counter. They are the final check. Often they find that ultimate responsibility daunting. To these new pharmacists, I say, just don’t let it become overwhelming.

    There’s a first time for everything. I still remember the first prescription I checked, on my first day as a new pharmacist, in August 1981. It was for Benadryl 50-mg capsules.


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