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  • Serious Dispensing Error. What now?

    I'm a trainee dispenser coming towards the end of my NVQ2. So far I have made a few predictable mistakes - more so with less common drugs that I am unfamiliar with. All of these have been caught in the final check and have never gone further than a near miss and I've worked hard to improve my accuracy using more thorough checking techniques.

    This week, during a CD balance check it came to light that a dispensing error has been made around the end of June. A modified release CD was dispensed instead of the standard version. To cut a long story short, we tracked down where the error was made and contacted the patient who has been taking the medication. Thankfully they don't appear to have come to any harm. They brought back the remaining medication, however had thrown all the packaging away so the dispensing initial on the label cannot be traced.

    Obviously we need to wait for the Rx to be tracked down but I'm told this could take up to six weeks. Myself and four other dispensers were on duty that day, but as the trainee and least experienced member of staff I feel it is likely to have been my error. Discussed with the boss and a couple of things ring a bell about dispensing a similar Rx however I can't be sure if I'm imagining things in my panic.

    I am absolutely mortified, not sleeping and my confidence is shot. I don't know what to expect if it was me and I can't stop going over the details in my head.

    I know a report and investigation will follow and my main concern is that no harm came to the patient, however I can't find any information about how this will affect me and my training. Will I be disciplined or not allowed to finish my NVQ?

    I love this job and I'm gutted I might have made such a serious error. My pharmacist has been brilliant in dealing with it all and has told me not to worry but I can't help it.

    Any information or advice would be appreciated. I'm worried the knock to my confidence and following uncertainty is going to end up in more mistakes.

  • #2
    First of all - the drug molecule and the strength was the one intended.
    The patient has suffered no harm.
    That is such a relief to hear.
    So next is a lessons learned exercise and a review of the processes.
    Write down on paper what you have learned and the process you are going to follow.
    You could try the trick with appliances and that is to read the medication backwards which avoids word familiarity.
    Example for you.
    Morphine 100mg modified-release capsules
    Read as
    capsules modified-release 100mg Morphine.

    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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    • #3
      I wouldn't assume it was you. Dispensing errors happen and like outlined, because it wasn't picked up on a lot of information is lacking and all sorts of things go on, sometimes people playing mind games and blaming people - not the case here fortunately.

      Bit that worried me, was depending on when the CD balance is done and end of june is, there could have been two CD balance checks done and only picked up on the second one.

      Do you have anxiety opening post?

      I doubt very much you will not be allowed to finish your NVQ2. Other possible consequences, don't seem that likely, but you never know.

      The thing is to reflect on the errors and also reflect on the type of errors generally you and importantly other people in your team make. E.g. picking errors. Similar box errors. Similar name errors. Which medications get strengths confused. The medications with different release.

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      • #4
        I have made a few CD errors. Very worrying. Luckily all were resolved OK.
        Each time I was the only person in dispensary and one happened when looking after health care counter as well.
        johnep

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        • #5
          Thanks for the replies.

          I've been back at work and nobody seems to be saying much about it. I suppose there's not much else to be done until the report of what happened is looked at but I feel a bit out of the loop.

          I would rather just know if it was me and face the consequences than have it hanging over me. The other dispensers don't seem to be as worried that it could be their mistake.

          I'm aware that everybody makes mistakes, but this is a big one, and I may have been imagining it but I feel my manager has been looking over my shoulder alot more and giving me reminders which he hasn't done with other staff.



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          • #6
            I'm not sure what you mean by "anxiety opening post" mcitr

            Comment


            • #7
              Originally posted by catsdontcare View Post
              Thanks for the replies.

              I would rather just know if it was me and face the consequences than have it hanging over me. The other dispensers don't seem to be as worried that it could be their mistake.

              I'm aware that everybody makes mistakes, but this is a big one, and I may have been imagining it but I feel my manager has been looking over my shoulder alot more and giving me reminders which he hasn't done with other staff.
              The other dispensers may be less worried as they've seen it before. I've seen several big dispensing errors where they never worked out who did it for sure, or the people investigating it were not the sharpest people around, or not bothered or picked up late or nothing came of it. Or some people just don't worry.

              There are much bigger mistakes. What you are telling us if it is your first dispensing error. That's pretty good. Also the pharmacist should have picked it up and it looks like it should have been picked up quicker in terms of CD balances.

              Comment


              • #8
                Originally posted by catsdontcare View Post
                I'm not sure what you mean by "anxiety opening post" mcitr
                A very simple question. Do you have anxiety? Which you don't have to tell me anyway.

                https://www.mind.org.uk/information-.../#.XSeUOuhKiUk

                https://www.mind.org.uk/information-.../#.XSeUdOhKiUk

                Comment


                • #9
                  Originally posted by mcitr View Post

                  A very simple question. Do you have anxiety? Which you don't have to tell me anyway.

                  https://www.mind.org.uk/information-.../#.XSeUOuhKiUk

                  https://www.mind.org.uk/information-.../#.XSeUdOhKiUk
                  Sorry, the "opening post" threw me.

                  Yes I do, so I'm also trying to be mindful that it's likely to make me more worried than is "natural".

                  Thanks for the links.

                  Comment


                  • #10
                    Originally posted by catsdontcare View Post

                    Sorry, the "opening post" threw me.

                    Yes I do, so I'm also trying to be mindful that it's likely to make me more worried than is "natural".

                    Thanks for the links.
                    There should be a comma in there somewhere , I am sure people do also get anxiety from opening post .

                    Self kindness would be the most important aspect of this thread for me here in that case if you do.

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                    • #11
                      Yes it is the brown envelopes that worry me the most.
                      johnep

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                      • #12
                        With out being rude, as a trainee I am surprised that you are allowed to make up CD rx. Not sure if this is just our pharmacy but we have it in our SOP's that anyone making up CD rx should be a level 2 and should of been passed for 6 months before doing these. Xx

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                        • #13
                          I didn't do it when I first started dispensing, I would leave any schedule 2 and 3s to the side for another dispenser to do, but I've been doing them for a few months now.

                          Because of what happened we have all been asked to re-read the SOPs and there is nothing mentioned in ours about trainees but I will bring it up with my manager tomorrow. I have dispensed more of similar since the incident with no mistakes and nobody has advised me not to.

                          I'm not sure if the rules differ between pharmacies so you could be right but generally speaking my manager likes to do things by the book and that would be a pretty big oversight if I shouldn't be doing this yet!

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                          • #14
                            Originally posted by catsdontcare View Post

                            I'm not sure if the rules differ between pharmacies so you could be right but generally speaking my manager likes to do things by the book and that would be a pretty big oversight if I shouldn't be doing this yet!
                            Rules differ wildly between pharmacies on CDs. Within chains, local variations sneak in.


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                            • #15
                              Remember that unlike any other profession, making a dispensing error is a criminal offence. Poor Mrs lee had her house searched and she was treated same as any other "criminal" by the police, including being asked she was a member of a criminal gang. Nearly 20 years ago I attended a meeting seeking to decriminalise dispensing errors but as yet believe law has not been changed. Or has it?
                              johnep

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