Get the correct patient!

[admin]

Hi.......pour yourself a large brandy...........

Hell what a mess I have had today. The pharmacist yesterday had given a woman's drugs to a very old confused man. The SOP states you should always check the patients name and address, but we looked at the CCTV of the pharmacist giving out the script, and it appeared that nothing was said.

So that led to a confused guy going home with a womans drugs. He ignored about half of them, but last night took: -

1 x 50mcg thyroxine (labelled 100mg)
1 x 150mg tradazone tablet
1 x 5mg amlodipine tablet
1 x 20mg simvastatin tablet

He lived in sheltered housing, and the warden wanted to take him to hospital last night, because he was so groggy from taking the trazadone. He was a grumpy kind of guy and refused to go to the hospital.

He was still a bit groggy this morning when he came back in the shop, and didn't really realise what was going on. His own medication was in the shop, waiting for him to collect - safely put away yesterday! He eventually (not yet) left the shop with the correct medication, but I was concerned he might suffer a fall, or step under a bus or something! He wouldn't listen to any advice, and got very agitated as he just wanted to leave.

When I opened up the drugs he had been given (and had just returned), among it there were 50 and 100mcg thyroxine, but the labels were the wrong way round on two boxes of each i.e. four boxes had been incorrectly labelled.

The fun didn't stop there. The husband of the woman came back in, the same time the old man was in the shop. The pharmacist yesterday had simply re-dispensed his wifes drugs, but I'm not sure why he didn't try to get the wrong bag back from the old man, as the store does have a driver, but maybe he didn't realise the mistake he'd made.

Anyway, when the womans husband brought back her drugs, three of them were missing! The packet was unopened, so the only conclusion I could come to were that they were indeed omitted from the original dispensing. When I say three drugs I mean she had co-prox and trazadone missing and her husband had co-prox missing. The old guy had the womans drugs, so had a packet of co-prox to go at as well, fortunately he hadn't touched any of them. I wasn't going to let the old guy go, until I knew exactly what he had taken, in case he had overdosed on something and did need the hospital. Thats when I found the tablets he had taken, and attempted to try to explain to him what had happened, and made sure his own drugs were correct. After that and a lot of grumbling he left with the correct drugs.

So basically the old guy had the womans, but the four boxes in total of thyroxine were wrongly labelled, and the woman had her own and her husbands drugs, but three of them were missing! I'm not even sure how many mistakes this all adds up to!

Then this led to talks with the old mans nurse, his GP practice manager etc. The area manager was called in, and will be visiting the store tomorrow.

At the peak of this, I had a 1 year old child prescribed phenergan elixir, which is clearly stated is not for anyone under the age of two, and I was on the phone to the childs GP at the same time as trying to sort this mess out. The old guy was there, all confused and agitated, and a man wondering why that old guy over there had his wifes drug all at the time I was in the middle of speaking to a GP and he was talking to another GP at the practice!

I did as much as I could in the circumstance, but was glad to get home at around 7pm.

The moral of this story is MAKE SURE YOU ARE GIVING DRUGS TO THE CORRECT PATIENT !!!

The knock ons from this simple error can be massive.

[alex]

Another good day in the pharmacy then?

... your horror stories make me think you must have some darned good relaxation techniques in order to be able to hack it... i'll have to get some tips off you for when i start!

Wow! Some day. I did over 40 years retail pharmacy before retiring and I never had a string of errors like that.
Surely someone is a danger to the public here?

[Linnear]

Good locum then huh?

I heard today that one in three workers turn to drink for stress! Only 1 in 3 I was shocked! Would ahve thought much more than that!


My run in with a PCT was due to a pharmacist giving the wrong Rx to a patient. Trouble was it was for MST!

The patient that should have had it came back for it and of course was told she'd already had it and the Dr accused her of being an addict!

I was at the shop when the PCT rang to find out what was going on and the PCT woman started shouting at the dispenser! I spoke to her and asked why she wasn't having a go at the pharmacist or even area manager as it was a CD error. Her tone changed as she knew that she was in the wrong. I sorted the error got the Rx picked up and sent to the right person, reported the error to Head Office and apologised. The PCT woman then reported me for not taking the complaint seriously enough.

I then wrote a letter of apology which apparently didn't help! I can be twice as big a b*stard when I'm apologising as when I'm being abusive!

And that's how my anti-PCT vendetta was born!

[admin]

Hi All

Today I was working at a store within about half a mile, from the one I was at yesterday. The store today was really busy, and the manager had to do dome MUR's so I was there. I had to run an errand to the shop I worked at yesterday - where the mistakes were made.

I went in all cheerful and said "morning, how's things" to the pharmacist who had made the errors. What has really got up my nose all bloody day is that he just ignored me! I was stood about two feet from him, talking to the area manager, and he didn't even make eye contact with me. Not a "thanks for saving my arse!" or anything of the sort! Not even a "thanks for sorting out my mess!". I was told he'd just been told to follow SOP's and that's it.

[admin]

Originally Posted by alex

Another good day in the pharmacy then?

... your horror stories make me think you must have some darned good relaxation techniques in order to be able to hack it... i'll have to get some tips off you for when i start!

This kind of thing doesn't happen often Alex, and it's not meant to be a horror story, just a warning of the dangers of not making sure you are giving the drugs to the correct patient. In the past I have myself shouted a name, lets say "John Smith" and some guy has said "yes, that's me". I have then said "John Smith of 1 High Street" and the guy has said "yes, that's me". The same guy returned an hour later shouting at me saying "why have you given me John Smith's tablets, when I'm David Jones!" I don't know why, but people will often answer to the wrong name. That's why you should always ask them to confirm their address to you, and not just give it and wait for a "yes".

As for relaxation, that's what your days off are for! I'd suggest golf, fish and pop concerts for starters! Also maybe start a little computer hobby, like a forum, so you can get it all off your chest!

[alex]

Poker and Pink?!
Sadly, doesn't sound healthy to me either!!

Sadly, I've had the experience of giving out a prescription to a guy who answered to a name I called out, before I knew to ask for their address....
... luckily, no harm came of it and it's taught me to ask for their address if I give out any presciptions

[Pharmanaut]

Originally Posted by admin

Hi.......pour yourself a large brandy...........

Hell what a mess I have had today. The pharmacist yesterday had given a woman's drugs to a very old confused man. The SOP states you should always check the patients name and address, but we looked at the CCTV of the pharmacist giving out the script, and it appeared that nothing was said.

So that led to a confused guy going home with a womans drugs. He ignored about half of them, but last night took: -

1 x 50mcg thyroxine (labelled 100mg)
1 x 150mg tradazone tablet
1 x 5mg amlodipine tablet
1 x 20mg simvastatin tablet

He lived in sheltered housing, and the warden wanted to take him to hospital last night, because he was so groggy from taking the trazadone. He was a grumpy kind of guy and refused to go to the hospital.

He was still a bit groggy this morning when he came back in the shop, and didn't really realise what was going on. His own medication was in the shop, waiting for him to collect - safely put away yesterday! He eventually (not yet) left the shop with the correct medication, but I was concerned he might suffer a fall, or step under a bus or something! He wouldn't listen to any advice, and got very agitated as he just wanted to leave.

When I opened up the drugs he had been given (and had just returned), among it there were 50 and 100mcg thyroxine, but the labels were the wrong way round on two boxes of each i.e. four boxes had been incorrectly labelled.

Hi,
Anything that could be fed into Operation Watchdog from this?

On another tack, early in my career I refused (politely) to give a prescription out until the person could tell me an address, the script had been dispensed the day before and none of the staff recognised him. The chap's wife then called me and told me that it was the first time he had been out for ages after being diagnosed with parkinsons and he was so upset when he got home. All sorted out though, took the prescription round myself and spent half an hour with a cup of tea in the chap's greenhouse talking about growing grapes. Funny world pharmacy.

[admin]

Originally Posted by norcot

Wow! Some day. I did over 40 years retail pharmacy before retiring and I never had a string of errors like that.
Surely someone is a danger to the public here?

I have been told this is not the first time this sort of thing has happened here, but it all depends on your luck doesn't it! I know one pharmacist who has put 3 people in the hospital, two with the wrongly dispensed strength of digoxin. Having said that her father is a local GP.

[Linnear]

Have had a couple of good ones this week. One old man who had 60 MST 15mg delivered and his daughter couldn't find them. Talk about your life flashing in front of your eyes!


Then an old biddy came in and asked me to ring the surgery to get authorisation to give her 2 tabs to see her thru until her Rx that she had just ordered arrived.
The surgery said tell her to come up and we'll do a Rx for her today.
So I told her (politely, before any of you say anything!) that I couldn't give her an emergency supply because of what the surgery had said and now she's going to put in an official compalint against the "uncaring" pharmaacist that didn't even think of her ulcerated foot, which I should ahve known about because she had a dressing Rx the week before or her chest infection that I should ahve deduced from her Flucloxacillin Rx from 5 days before!

I'm just a b*stard me!