No "no blame culture" anymore?

[admin]

Hi Everyone

I worked in a pharmacy that I usually do this week. The manager was putting into piles the reports of errors that had been done in the pharmacy. He was making a pile for each person that had done the error. Most did not reach the patient, but a few did. Fortunately there were no consequences.

So then I came across this article: -

http://www.pjonline.com/Editorial/20.../statcomm.html

If you read it, the interesting parts are: -

Mr Adekaiyaoja had on occasions worked 46 hours or more in a week, including shifts of up to 14 hours.

Can anyone concentrate after working that long? Is there any wonder he made mistakes?

Mr Hardy told the committee that he might have given Mr Adekaiyaoja too much leeway. He added: “Where we probably went wrong was trying to operate a culture of ‘no blame’ where we encouraged people to tell us about the dispensing errors. We have now changed that.”

So the company has now changed that to what? Will anyone ever report an error there ever again?

This guy did six dispensing errors, but one is listed as: -

The supply of Medisense G2 sensor electrodes labelled as Medisense G2 test strips in response to a prescription calling for 4 x 50 Medisense Soft-sense test strips.

Is there anyone out there who has not got these things mixed up in the past? I am not saying making dispensing errors is acceptable, but everyone makes them. If you get caught then you are in trouble, but if you hide them well enough you are ok - is that right?

“All in all,” concluded the chairman, “his conduct is to be regarded as reprehensible and, in our view, his conduct was not only such that he is unfit to be on the Register but we direct that his name should be removed. If there are circumstances in mitigation, which we doubt, none was presented before us, notwithstanding the fact that every opportunity was given to Mr Adekaiyaoja so to do.”

The people at the Statt Comm consider sitting there from 9.30am to 5.00pm to be a long day - anyone think to mention this guys 14 hour shifts?

Why isn't there a step that the statt comm can take, like say a period of re-training under supervision, until the pharmacist is signed off as to be competant again? Why do they regularly ruin people's lives, when the Shipmans of this world still work after being found to be addicted to morphine? Why can Dr's get away with virtually murdering people, and mistakes done by us get hit so hard? Why do we put up with this?

Why don't we all refuse to pay our fees and see what happens?

[Jeff]

Why don't we all refuse to pay our fees and see what happens?

Too late - my wife has already paid mine on-line.

Which (to Linnear) is also a reason on-line revalidation wont work.

Jeff

[Linnear]

Too late - my wife has already paid mine on-line.

Which (to Linnear) is also a reason on-line revalidation wont work.

Jeff

Sorry, lost me there. Do you mean that there's no way of knowing who's sitting the exam? Which is a very good point!

We live and learn. I've always said that I'm not so bad that I won't accept when I'm wrong. I thought I's come up with a good way of revalidating.

But a thought has just struck me how can the CPPE know if any of us are doing the courses. All the certificates they hand out could all be being done by one super intelligent pharmacist and the res5t of us just pay him to answer the questions!

Hold on! I could be that Super Intelligent pharmacist! How much should I charge?

[Zoggite]

Lord Fraser of Carmylie said:
"pharmacists are regularly disciplined in cases where the original error lies with the doctor, who escapes any form of disciplinary sanction."
This was part of his comments as Chair of a Statt Comm hearing of a rather well-known phcist who had dispensed bisoprolol tablets 10mg, prescribed and labelled "take eight tablets daily"...

[Pharmanaut]

Why don't we all refuse to pay our fees and see what happens?

What will happen is that you will get your name "removed from the register". You will then have to pay extra to get back on it!

You have to bite your lip and pay up.

[admin]

What will happen is that you will get your name "removed from the register". You will then have to pay extra to get back on it!

You have to bite your lip and pay up.

I know, you're right. I always wait until the final demand though as I figure that costs them a bit of cash!

[kemzero]

Could those who have never made an error ,raise their hands please? Thot so ....

We must all oppose the section 60 order....as things would only get worse (not better!)

[mr_colt]

While pharmacists are expected to be diligent; it really annoys me that some of these GP's regularly make some serious mistakes in drugs perscriptions and are let off with a slap on the wrist.

Having formed a good relationship with the ward pharmacist during my last stay in hospital while i had c.diff; she let me know exactly how she felt about a good few of the Doctors. Unfortunatly it would be un-repeatable here unless I wanted to get banned on my second post. Still It's unfair she regularly has to spend time stopping Doctors from harming or killing their patients by not checking what theyre perscribing.

For example my discharge sheet said to dispense "20mg Tolterodine qds prn" 20mg!!!!!! Drop the zero doc

It brings me back to stories from the USA when some docs got:

DTO (De-odorised opium tincture (Laudanum) mixed up with
CTO (Camphorated opium tincture (Paregoric)

As you know Laudanum contains 25 times the morphine content of Paregoric. Yet docs were perscribing Laudanum with Paregoric doses

Fortunatly there werent as many deaths as there could have been thanks to pharmacists thinking twice rather than just blindly dispensing the Rx.

Since then strict instructions have appeared in the AHFS ensuring docs use only the names: De-odorised opium tincture and Paregoric to ensure there is no confusion.

Ironically under all this I receive Ondansetron off license for IBS-D from my consultant gastro, though it was I who approached him about trying 5HT3 antagonists and since I have been on them I've been given my life back. Perhaps if the MHRA wasn't so snotty about new 5HT3 antagonists then I wouldn't have to do this. My GP obviously refuses to perscribe on instruction the Ondansetron; he is quite content to try very high doses of Amitryptyline off-license (quite a dangerous psyco-active med these days.) as a way to control the seritonin levels reaching the enteric nervous system. It didn't work either.

Over in the US: Despite the low risk of Ishemic colitus; Alosetron (Lotronex) got re-instated because for many people it's the only effective treatment. Thousands of people were willing to travel to Washington in Adult-diapers to testify in front of the FDA as to how losing Alosetron meant losing their health, freedom and independance. Yet I fear that the euro counterpart Cilansetron will never arrive on these shores.

One would put forward the point that some of the GP's of today care more about the cost of the drugs perscribed than the health and wellbeing of the patients.

Regards,

mr_colt

[howe928]

Why isn't there a step that the statt comm can take, like say a period of re-training under supervision, until the pharmacist is signed off as to be competant again? Why do they regularly ruin people's lives, when the Shipmans of this world still work after being found to be addicted to morphine? Why can Dr's get away with virtually murdering people, and mistakes done by us get hit so hard? Why do we put up with this?

Why don't we all refuse to pay our fees and see what happens?

yeah, i agreed totally, no blame culture is not exist at the moment from what evidences have shown, heard people talking about it but still need sorting out

other suggestion is: letting the pharmacist do clinical check and MUR but not accuracy check, get an accuracy checker in working alongside him (this might be the future of community pharmacies)

how about limiting volume of items allowed to be checked legally per working shift? the only barrier to this is cost of implementing this but i believed patient safety is worth all the cost

some pharmacists checked items off but leave it for staff to bag them up, i do not think this is good idea or good practice, first they skipped the final check of items against presciptions before they put items into bag, second something could have dropped into the basket (a little bit extra - but it is not money but danger! danger!) third the bag label could be stucked to the wrong basket, fourth the staff who put items into bag does not check they just bag whatever in the basket up into bag. A risk there really! For this, i think the pharmacist should be punished more heavily for the dispensing error (if any) occurred this way.

hopefully the new reformed pharmacy body will take these issues onboard