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What happens if you make a serious error?

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  • What happens if you make a serious error?

    I dispensed insulin (the wrong one to that on the script), and it wasn't checked by the pharmacist for some reason and was just given out. What happens in these situations, because since working in this VERY busy pharmacy many mistakes have happened (not by myself, this was the first) and it always seems that the dispenser or tech is blamed while the pharmacist gets off. I feel I'm going to get the main blame for this, even though it wasn't doubled checked.

    Note: patient realised the error and brought the meds back without using it.

  • #2
    Originally posted by Jen_here View Post
    I dispensed insulin (the wrong one to that on the script), and it wasn't checked by the pharmacist for some reason and was just given out. What happens in these situations, because since working in this VERY busy pharmacy many mistakes have happened (not by myself, this was the first) and it always seems that the dispenser or tech is blamed while the pharmacist gets off. I feel I'm going to get the main blame for this, even though it wasn't doubled checked.

    Note: patient realised the error and brought the meds back without using it.
    Hi,

    Insulins are a high risk medicine, particularly because there are so many types in terms of how they act (rapid, e.g. Novorapid, short, e.g. Actrapid, intermediate, e.g. Humulin I, long, e.g. Lantus glargine, and bi-phasic, e.g. Novomix) , but also in terms of the devices, (cartridges, vials, pens). To make things even more complicated, there are insulins that are of a higher strength - the standard used to be 100 units/ml but now you can get insulins that are 200 units/ml, and even 500 units/ml for patients who require large amounts of insulin. As a result, when dispensing insulins, it is very important to be certain that you are dispensing the correct one. In our hospital all insulin prescriptions are checked twice independently after dispensing - either two pharmacists, two technicians, or a technician and a pharmacist.

    With regards to your specific query, it is not your fault alone because it was not checked before handing out to the patient, which is not great really. However it might be worth doing some CPD on insulins and the importance of dispensing the correct one.

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    • #3
      It shouldn't be a blame game, each error should be a learning experience.

      In reality the pharmacist is always ultimately responsible for any error that goes out but the easiest learnings and changes after an error will be in the dispensing process and not the checking process.

      Most pharmacies have in their SOP's that a double check should be completed at handout by the counter assistant with the patient so there's a learning opportunity for all involved by the sounds of things.

      All you can do at this point is be thankful no harm came of it and learn from it.
      I remember when a blog was an individual boot.

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      • #4
        Simple solution is to get the insulin checked by a colleague or pharmacist against the actual prescription before it is labelled and before it gets put in any basket.
        Another tip is to read the name backwards again once you have picked from the fridge (not the letters of the words but the description phrases). This stops the brain from seeing patterns and makes it focus on making sense of information.

        Here's an example. Humulin M3 KwikPen 100units/ml suspension for injection 3ml pre-filled pen (Eli Lilly and Company Ltd)

        Eli lilly and company ltd. 3ml Prefilled pen 100units/ml suspension Kwikpen M3 Humulin.

        If you want to see how the insulins compare there are some really good charts available.
        https://www.diabetes.org.uk/resource...rtinsulins.pdf

        Another safety net is to show the insulin(s) to the patient for confirmation when the prescription is handed out.
        47 BC : Julius Cesar : Veni Vidi Vici : I came, I saw I conquered.
        2018 AD : Modern Man : I shopped, I clicked, I collected.
        How times change.

        If you find you have read something that has upset or offended you an anyway please unread it at once.

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        • #5
          What do you mean it was not checked? So pharmacist did not check it at all or did they check it but just not see the error?
          If you gave out anything without it being checked then technically you're breaking law and it's your fault. Obviously if the pharmacist forgot to check and they bagged it up anyway and you had no way of knowing it was not checked, then it is the pharmacist's fault.
          Pharmacists must ensure to check all medicines, dispensers/technicians would not know different between insulins etc so pharmacist must always check.
          You should have an error log in your pharmacy and log all these errors in.

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