Pharmacists write in: Worst mistakes, Part 1

Dennis MillerI received a lot of interesting feedback from my recent three-part series on pharmacy mistakes: “My most serious pharmacy mistake” (July 1), “Who is to blame for pharmacy mistakes?” (July 22),and “State BOPs and public safety” (August 5).

One pharmacist wrote to me, “Getting a pharmacist to admit an error is like trying to get a woman who has had an abortion to talk about it. It is not going to happen.”

Apparently many pharmacists disagree, seeing significant educational value in discussing their errors. Typical of these, another pharmacist wrote, “Thanks for sharing your experience. I think hearing about other people's mistakes is a great way to hopefully prevent them from happening again.” 

With that thought in mind, I am sharing a small sampling of the e-mail I have received.

See also: "My most serious pharmacy mistake"

Real-world pharmacist errors

Pharmacist #1:  “My biggest error was dispensing terfenadine (Seldane) to a patient on quinidine. I contacted the cardiologist but he said that's what he wanted, so I dispensed it. The patient ended up dying of sudden cardiac arrest a few months later.”

Pharmacist #2:  “I made a mistake which will forever haunt me. U-500 insulin, gave 350 units rather than the desired 70 units. Sent the patient to the ICU overnight (recovered fine). Inexplicable! I knew the insulin, knew the risks, I completely knew better, and still made this damned mistake! Still makes me feel so stupid every time I touch ANY insulin. Probably a good reminder, but it still hurts, years later.”

Pharmacist #3:  “I guess I should be taken to the whipping post too. My worst error was when I was an intern (40 years ago). Gentamycin dose of 39 mg. Didn't catch that it was for an infant. No harm done, but I never forgot it.”

See also: Who is to blame for pharmacy mistakes?

Pharmacist #4:  “In 2008 I filled a triplicate Rx for morphine ER 200 mg TID. The Rx was an original from a pain specialist who had been treating our mutual patient, an elderly female, with hydrocodone/apap 10/325 TID plus an Rx for carisoprodol.

“Knowing the patient and the doctor, I filled it. It was in his handwriting on a triplicate form. Thinking she had taken a turn for the worse, I did not question it.

“She took one dose and ended up in the ER. After she was released from the ER, she immediately contacted a lawyer and tried to sue my pharmacy and the MD.

“I ended up paying for her ambulance ride to the ER and a fine from the board of pharmacy. The pain specialist who wrote the rx suffered no repercussions.

“At the time I was afraid to question the all-powerful pain specialist. How dare I question his prescriptions!

“Should I have been disciplined? Now I would say yes. Should the MD who wrote it have been cited? I think if I was in error, he was complicit in that error.”

Pharmacist #5:  “I was in my first or second year out of school, working in a 250-bed hospital. A nurse came to the pharmacy, wanting floor stock heparin flush.
“I went to the heparin shelf, not knowing what I was doing, and selected a box of 5000 unit heparin, not flush. At the time, I didn't even know that there was a difference in heparin to flush a line and heparin to anticoagulate. I handed it to the nurse without a thought.

“It turned out the nurses flushed with the full strength heparin that I dispensed and they had to do heroic reversal of the life-threatening thin blood it caused one patient.

“At every pharmacy where I have worked since then, I have separated the heparin flush from the regular heparin and put a big sign by the regular heparin that said, ‘NOT FOR FLUSH.’”

Pharmacist #6:  “Luckily in 26 years I haven't personally made too many big ones (that I know of). But funny, I do remember my very first - wrong strength of penicillin for a pregnant lady. That one worried me more than most, and every penicillin I fill reminds me of that one so many years ago.”

Pharmacist #7:  “One of our pharmacists filled a prescription incorrectly with Amoxil 250 mg instead of the written Amoxil 500 mg. The error was discovered on the refill.

“The patient filed a complaint with the state board,which contacted my employer, and two other pharmacists and I had to appear before the board.

“Since there was not any proof on the Amoxil Rx who filled it, being the manager, I went as a representative of the store, the other pharmacists, and the company. The lawyer engaged by the company advised me to just accept whatever disciplinary action was meted out and not to contest it. The lawyer was someone who often appeared before the board in defense of pharmacies and pharmacists.

“I was interviewed by one member of the board, who was not a pharmacist but was the lay person on the board and the board’s attorney. The board member was very incensed over the error, even though the patient was fine, no excess illness or injury had occurred, and recovery was complete. After the board member chastised me for 10 minutes, I was told a formal reprimand would be put in my file. 

“The lawyer, in retrospect, gave me bad advice. If nothing else, I was a good soldier who took a hit for the team.”

Pharmacist #8: “I have been working chain pharmacy since I graduated. It only took me two years to have my initials land in the "Recent Board Discipline" section of the state board newsletter. The entry is fairly anonymous and read something like this: "[Pharmacist’s initials], $500 and 6 additional CE fine for failing to...' 

"Never at any point have I felt ashamed about it, though sometimes I'd like to have that five hundred bucks back.  

“The situation was this. A regular customer came in to pick up several things and drop off a Fioricet Rx. It was oddly not too busy at that moment, so I had it entered in the computer and reviewed quickly. About nine months later, my Rx supervisor informed me that the board would fine me for the Rx.

“I had incorrectly typed it as Fioricet w/codeine. When the 1+5 total fills had expired and we went to renew it, the provider renewed it as [plain] Fioricet. The patient complained to the provider that Fioricet w/codeine worked much better and demanded that.

“Probably frustrated by my mistake and the patient's demands, the provider decided the board needed to punish me.”

Pharmacist #9:  “Worst mistake:  Merital 100 mg every morning and 2 p.m. I took it as 1 in the morning and 2 in the evening.  Should have been 1 cap in the am and 1 cap at 2 p.m. I think she got sick, but didn't go to hospital. Anyway, they still traded with me.”

Pharmacist #10:  “My worst mistake as a pharmacist was a handwritten prescription for Haldol, which my technician mistakenly typed for nadolol. I did not catch the mistake, and the patient took the medication for a few days before returning to the pharmacy. We corrected the prescription and let the patient's doctor know.

“The patient was fine, but it could have been disastrous! I agree with you that I punished myself hard for this one and have had self-doubt since, especially on handwritten prescriptions.”  

Most of the time, you know why

Unlike fictional dramas on TV, there is no dramatic music playing in the background during those moments when a pharmacist’s attention lapses and he makes a mistake. 

Those errors occur when we’re overwhelmed with prescriptions in a dangerously understaffed pharmacy, when we’re dead tired from standing on our feet for 10 to 14 hours, and when we haven’t had time to sit down for a few minutes and grab a few bites to eat. 

On the other hand, sometimes errors occur inexplicably, for none of the above reasons.

In my opinion, discussing real world errors among pharmacists can be educational, and it surely makes pharmacists more careful.

With the possible exception of the pharmacist who dispensed terfenadine (Seldane) to a patient on quinidine, none of the pharmacists who sent me e-mails described a misfill that resulted in a patient death. I suspect most pharmacists would view it as too painful to discuss those errors. 

The nightmare cases

While researching my book Pharmacy Exposed, I found many cases in which pharmacy errors resulted in multimillion dollar awards.  Can you imagine the burden a pharmacist would carry on his shoulders for the rest of his life if he were responsible for any of the following errors? 

• $31.3 million award in Illinois: Pharmacist dispensed diabetes drug glipizide to Leonard Kulisek instead of gout drug allopurinol, leading to renal failure, stroke, and death

• $30.6 million award in California: Pharmacist dispensed 100 mg of phenobarbital to Bryn Cabanillas instead of 15 mg prescribed; brain damage

• $25.8 million award in Florida: Pharmacist dispensed blood thinner warfarin in 10 times the dose prescribed to Beth Hippely, causing cerebral hemorrhage; teenage pharmacy technician’s error

• $21 million judgment in Illinois: Pharmacist dispensed adult diabetes drug glipizide to infant girl Alexandra Gehrke instead of anti-seizure drug phenobarbital

• $18.5 million jury award in New Jersey: Pharmacist prepared contaminated chemotherapy, which was injected into the spine of Anton Weck, causing paralysis

• $16 million award: Pharmacist dispensed adult diabetes drug Glynase to young girl instead of Ritalin; brain damage

Is there an error that is forever seared into your brain, the one you wish you could do over again if you had the chance? You can e-mail me at dmiller1952@aol.com and get it off your chest.

Next week, look for Part 2: What your fellow pharmacists are saying about pharmacy mistakes.

Dennis Milleris a retired chain-store pharmacist living in Delray Beach, Fla. He welcomes feedback at dmiller1952@aol.com. His books Chain Drug Stores are Dangerousand Pharmacy Exposed are available at Amazon.com.