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  • Errors made as an act

    Hi,
    i am a act, qualified for 5 years - checked regularly and have never made a mistake. I was only probablah checking 100ish items per day. These would mostly be nomad trays.
    We have recently set up a dispensing hub working with a robot which deals with around 750 patients per mth. When tracking number of items checked it regularly around 800ish items. This number will be increasing as we are also taking on care homes.
    I am one of 2 acts checking these trays, and have been doing so since returning from maternity leave in the summer last year. I have so far made 3 errors. These are mistakes that have been found by patients.
    I feel my confidence is completely shot, I’m questioning everything and am absolutely terrified of making another error.
    There are 4 of us working in the department - the other act and dispenser have come from a chain pharmacy which was set up much the same as our department and are very used to dealing with such high numbers of items to check.
    I just don’t know where to go from here

  • #2
    We’ve all been here!

    5 years with out a mistake is exceptional and unusual. It may have lead you into a false sense of security, because the truth it, mistakes happen.

    we are human and not infallible.

    i don’t know if others have found this but I tend to have a long spell with no mistakes then 2 or 3 will happen within a few weeks if each other. You can guarantee it.

    toure checking more than ever before, you’re in a new environemnt and it will make you feel bad - and that’s a good thing, it shows you have a conscience and care and will no doubt learn from this.

    take a deep breath, accept it’s going to feel a bit rubbish but more on learning from your mistakes.



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    • #3
      We don't go out to intentionally make a mistake.

      Do you know what the errors were and can you think what lead to them?
      Introspect on it once, then learn from what happened.
      Improve your way of working and carry on as normal.





      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.

      Comment


      • #4
        Sometimes changing your checking method can help, have a read of a few different guidelines and see if working through one is more robust. I hate checking robot trays too, much prefer the hand dispensed type. I use the 'help' method of checking and find it robust.

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        • #5
          At the risk of pointing out the obvious...
          Bear in mind that when checking medication you should always have the prescription (or token) in front of you and check from that.
          Never dispense from labels or MAR charts.
          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.

          Comment


          • #6
            I insisted on the packs from which tablets taken.
            johnep

            Comment


            • #7
              Originally posted by johnep View Post
              I insisted on the packs from which tablets taken.
              johnep
              Anyone else stopped and thought this?
              What a waste.
              The manufacturer spends thousands on packaging machinery, we then deblister, repackage and throw the origina packaging away.
              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.

              Comment


              • #8
                Originally posted by Pharmanaut View Post

                Anyone else stopped and thought this?
                What a waste.
                The manufacturer spends thousands on packaging machinery, we then deblister, repackage and throw the origina packaging away.
                EVER SO MANY years ago, in my hospital days, I was supervising a pre-reg's project on Nomad etc dispensing. A rep called to see us and was sent to my office. I asked him about stability of his products once out of the packaging, told him why and was asked "Why would anyone want to do that?" Told him and the reply was that he'd never heard of such a thing, and he would ask his company and get back to me. No, never did.

                Comment


                • #9
                  Originally posted by gemmybean View Post
                  Hi,
                  i am a act, qualified for 5 years - checked regularly and have never made a mistake. I was only probablah checking 100ish items per day. These would mostly be nomad trays.
                  We have recently set up a dispensing hub working with a robot which deals with around 750 patients per mth. When tracking number of items checked it regularly around 800ish items. This number will be increasing as we are also taking on care homes.
                  I am one of 2 acts checking these trays, and have been doing so since returning from maternity leave in the summer last year. I have so far made 3 errors. These are mistakes that have been found by patients.
                  I feel my confidence is completely shot, I’m questioning everything and am absolutely terrified of making another error.
                  There are 4 of us working in the department - the other act and dispenser have come from a chain pharmacy which was set up much the same as our department and are very used to dealing with such high numbers of items to check.
                  I just don’t know where to go from here
                  I’m pleased that you are concerned about these errors. Some people would just brush them off and forget them. My feeling as an ACT is that we should never make mistakes and that should always be our goal regardless of the number of items or the circumstances in which we work.

                  Your starting point in dealing with this is to work out why each mistake happened. Were you distracted? Was the packaging similar? How will you prevent such an error happening in the future?

                  My system with nomads when I’m the dispenser is to get a tray for each item, dispense the required number of tablets into each tray keeping the original packaging in the tray. Then the checker comes and I go through the list of items on the script showing the packaging for each item and recounting the tablets. Then the checker watches as I work through the script putting the required item in the correct box in the nomad. We then check labels and stick them into the nomad and make sure that everything is tickety boo before sealing it.

                  As you are repeatedly checking everything during the process any error should quickly become apparent and can be remedied.

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