Posted by: Benedict Lam16 MAY 2013
We’ve all been there. We have all probably done it, but it never gets easier.
It happened to me recently. I was, as usual, on my own on a Sunday. The dispensary had been left in a rather bad state. I tried as hard as I could to tidy the place up before we opened the doors. It was busy. I had one patient come in expecting his 15+ item prescription to be ready for pick up. It was not. I had to apologise and said I would do it as swiftly as I could. A queue started forming behind him. Not good.
What is worse is that some items on the prescription were not in stock, so I had to send a colleague down to another branch to “borrow” some items to fill the prescription. Another patient showed up expecting her prescription to be ready for pick up since she dropped it off on Friday. It is another prescription with a large number of items. Again, it was not done. Now I was becoming stressed.
I said to the healthcare assistant to give waiting times of at least 30 minutes until I sort these two large prescriptions. I remained calm throughout and dealt with each prescription as I normally would, knowing that those two patients were waiting patiently. I dealt with the first patient and he left happy. Good. Next patient. Done. She was very sympathetic and saw how busy I was (I was trying to hide my stress but she saw through it). I had a brief chat with her afterwards, thanked her for being patient and understanding (and said she is welcome anytime to visit me on a Sunday with queries). She left the store.
I cleared the rest of the prescription queue (thank goodness there were no requests for emergency hormonal contraception yet). I started putting away the split boxes of medicines and came to a particular box. Disaster strikes.
I had given the wrong medicine to the second patient. I checked the patient medication record quickly. No telephone number. The surgery will not be open until Monday. There was only one thing left to do: send a colleague to her house to explain to her about the error. Half an hour after my colleague left for the patient’s house, I received a telephone call saying the address is incorrect and nobody of that name lives there. Great!
As a desperate final attempt my colleague rang another branch nearby hoping in vain it would have a telephone number or a different address. It did not. I had to give up and told the store manager to call the surgery first thing Monday morning to get telephone number to get hold of the patient.
I rang the store throughout Monday to check for updates. The manager had left a message but was unable to get hold of her. My worry deepens. It was not until Tuesday morning, when I rang the surgery and asked for another telephone number that I got hold of her. I explained to her what happened and apologised. Fortunately, she was very understanding and again said she saw how under pressure I was that day. She said she will return the tablets to the pharmacy in exchange for the correct tablets. A deep sense of relief came through me.
No matter how many years you have practised, that horrible feeling never becomes less when you have discovered you have made a mistake. You start thinking about the worst case scenarios, such as “what if that patient was harmed and ended up in hospital”, “will I lose my licence to practise”.
I am grateful that nothing adverse has come out of my mistake this time, but there are other pharmacists who might have ended up in a similar situation, not because they were incompetent, and things may not turn out so well. It makes me think about the decriminalisation of dispensing errors saga. When will that day come? No pharmacist in the right frame of mind would go out to make errors and harm patients deliberately. So why is decriminalisation such a painful and drawn out process? Come to think of it, why was this law made in the first place?