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How do you feel after you’ve made an error?

18 Apr 2018

I’m going to give you a ‘mea culpa’ story. Except, as you’ll see, maybe that should be ‘nostra culpa’. And if you’re struggling with the Latin, don’t worry, quod mox fiet manifesta erit.

The thing is, I’ve just been involved in my third serious prescribing error in thirty years. Yes, I know, by saying ‘involved in’ rather than ‘made’, it sounds like I’m trying to distance myself from this cock-up. That’s because I am. After all, I didn’t start it. As in, it wasn’t actually me who keyed into a diabetic patient’s repeat template an alogliptin dose of 25mg four times a day.

I know. It hurts even as I write those words. Four times a day. A quadrupling of the normal dose. How did that happen? I’ve no idea, and nor does the doctor who made the entry.

It gets worse. The patient has been on this dose for about a year. That means that I have possibly – OK, probably – signed scripts with that incorrect dose. About six times. How? Easy. Pressure of work, unfamiliarity with the dosage of newish anti–diabetics, the assumption that anything on the repeat template is rubber-stamped etc. But, that is no excuse.

Oh, and did I mention that he was seen by a diabetic nurse for a ‘treatment review’, too, without anything untoward being noted? Which means that, as is always the case with a really significant event, the error was made by multiple individuals. In this case, three.

Although maybe we should make that four. And this is where ‘mea’ becomes ‘nostra’. Because the pharmacy dispensed that incorrect dose. Many times. Which is not to divert from the fact that this was categorically the practice’s mistake – besides, I don’t see why pharmacist should be expected to act as a safety net for doctors’ stupidity.

That said, I’m guessing you pharmacists would view yourselves as capable of, and responsible for, spotting errors of this sort as you dispense. But you didn’t. Repeatedly. Even, incredibly, when the patient coincidentally switched to a different pharmacist.

We realised, as we picked over the wreckage of this prescribing car-crash, that, while we can just about grasp how it happened in practice, we can’t grasp how it happened in pharmacy, too. Simply because we don’t really know enough about your modus operandi. That’s something that, even if your Latin is as bad as mine, only you understand.

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