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    Who is to blame for pharmacy mistakes?

    Dennis MillerDennis MillerMany pharmacists will reflexively react to the above headline by proclaiming that the individual pharmacist who fills the prescription — and no one else — is fully responsible for any and all pharmacy errors. I feel that the issue is much more complex than that. When multiple factors are involved, the issues may not be so clear-cut.

    See also: My most serious pharmacy mistake

    Before you send me an angry e-mail accusing me of looking for excuses to justify every error made in the pharmacy, consider the following.

    Two categories of error

    I worked in one store with a young pharmacist who used to make lots of errors. One morning, two different customers returned with different prescriptions he had filled incorrectly. At that time, another large chain was known to send error-prone pharmacists to corporate headquarters for a couple of days for a refresher course in error prevention.

    See also: Why I wrote "Pharmacy Exposed"

    One pharmacist who had worked quite often in the same store with that young pharmacist commented to me that he desperately needed to attend such a refresher course. She told me, “Yeah, they need to start forwarding his mail to him [at such a course].” Her implication was that this young pharmacist needed extensive retraining or a complete transmission overhaul.

    In my opinion, pharmacy mistakes can be divided into basically two categories, those that can reasonably be blamed on the dispensing pharmacist, as in the scenario recounted above, and those that can’t.

    See also: Pharmacy dispensing errors

    We all know some pharmacists who are an accident waiting to happen.

    Some of our colleagues simply do not seem to understand how high the stakes are with each prescription we fill. Under pressure of work, do they become less mindful that ultimately the patient's life may hang in the balance?

    And some do not seem to understand how eager lawyers are to take a huge bite out of our posteriors and that of our deep-pocketed employer.

    I have the greatest sympathy for those pharmacists who are extremely careful in filling prescriptions yet occasionally make a mistake for any of the following reasons: severe understaffing, inadequate number of competent techs, 12-hour shifts, no meal breaks, no bathroom breaks, etc.

    On the other hand, should we feel sympathy for those of our colleagues who are a real threat to the public safety? Are there some pharmacists who clearly deserve to be punished for errors?

    The goal for such punishment is to serve as a wake-up call to extremely careless pharmacists.

    See also: Does your pharmacy comply with quality assurance requirements?

    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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    • Anonymous
      A few months ago my pharmacy software company sent out an update that turned off all my clinical checking (i.e. allergies, dosing, interactions, duplicate therapy). We were training a new tech at the time so it was a little hectic and I didn't notice for a few days. When I called the help desk they acted like it was no big deal. Who would be on the line for any errors that could have happened (luckily none that I know of)? By law I would be the one to blame.
    • Mr. SLefkow
      The worst pharmacy mistake I ever made was to go to work for a chain (I'll not mention Walgreen's name). Lasted about four months until I realized I wanted to be a "community" pharmacist, not a corporate robot. Spent the next fifty-plus years making my life and that of my neighbors a bit better each day. The other errors -- Fiorinal tablet for capsule -- that kinda thing, don't deserve a mention.