I made a dispensing error last week but was brought to my attention by the patient today. I dispensed Atenolol 25mg tablets instead of Amitriptyline 25mg tablet. The patient actually took 2 of the tablets before bringing it to my attention. I am not happy about this error and will review my dispensing processes using the prescribed tools to make sure it doesn't happen again! The reason why I am writing this is because of the remarkable way this dispensing error was brought to my attention. I will hereby describe my interaction with the customer ( I am recounting this event as accurately as I can...and documenting it as close to the event as possible: In other words, it is as accurate as I can get it ).
Mrs M V:
'Hello Pharmacist, I was given this medicine by your pharmacist colleague the other day and I think I have the wrong drug. I have already taken TWO tablets from the pack. I thought they looked different but I assumed they were different brands of the same medicine. I now know that they are different because I checked on the internet and this drug that I was given is for blood pressure.'
Me:
Hello Mrs M V, I said with a smile recognising her to be a regular customer. I took the medication from her and checked it. Yes the prescription was labelled as Amitriptyline but Atenolol (both 25mg) was dispensed. To my horror, it was my signature in the 'checked by' box. So, I said to Mrs M V (not smiling now) that I dispensed the medicine and I accept responsibility for the error. I also said I cannot at the moment explain why it happened but I will review my dispensing process to make sure this doesn't happen again.
at this point Mrs M V cuts in:
Mrs M V:
'You couldn't have dispensed it because you were not here on that day'
Me:
'Yes Mrs M V, I might not have been here on the day you picked it up but I signed it and must have dispensed it. Nevertheless, I am very sorry (I looked and felt remorseful about the error). In any case, I have to record the incident in our books and inform your doctors about it. I personally don't believe the two tablets you have taken would not have done any harm but I will let your doctor know about it.'
Mrs M V:
'You are not going to get into trouble are you? I feel alright and if this medicines is the same as propranolol, I will be fine because I have used that before.'
Me:
'Thanks for that, but my main concern is that the error was made in the first instant and want to ensure it doesn't happen again.'
Mrs M V:
'You will not get into trouble over this!'
With that, Mrs M V left the pharmacy.
I documented the error in the usual way, informed her doctor and devised a series of next steps to avoid a repeat of the error.
Reflection:
Two things about this interaction with my customer stood out:
- Here was someone I have dispensed the wrong medication to and was looking for a host of different reasons to justify my error. Furthermore, she has already taken some of the medicines which could have been potentially harmful to her. Mrs M V is either crazy (which I am certain she isn't) or she understands from previous experiences in the pharmacy that this was an exception not the rule. She probably can see that I was genuinely remorseful about the incident.
- The second point I will like to make is rather chilling: When a pharmacy provides a great service to the customer, they will keep coming back and trust will grow between the pharmacy and the customer. If this happens a great deal of the time, then this trust may be absolute. So, when an error occurs, the customer is likely to think: Ha I know my pharmacist, he will not make an error, and then proceed to take what may later transpire to be the wrong (and possibly fatal!) medicine. We want our customers to trust what we do but whenever something is slightly different about their medication we must be able to create an environment where they can alert us to the discrepancies. It is on the back of this that I have decide to compose a poem which I call:Medicinebelow (apologies, I am no poet!):
Medicine
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Medicine is a wonderful thing
Medicine is a dangerous thing
Medicine is a double edged sword
Used carefully, Medicine can be brilliant.
I am an MUR Evangelist
I want to give you the right Medicine
I want to tell you how to use it properly
But because I am only human, I can make mistakes.
If I give you a Medicine
Which is different from what you are used to
Just check with me before you take it
Because you can never be too careful
So this is the deal:
I will make sure I keep my errors to the minimum
And you should let me know when you have a doubt
Because I will be devastated if I give a Medicine
That turns out to be harmful to you.
