Rookie Pharmacists and Misfilled Prescriptions

Summer has arrived, and that makes me very nervous. This is both high vacation time and the time of year when pharmacy graduates begin their first jobs as registered pharmacists. The combination can lead to serious problems; after all, if a rookie floater is out of his league in a high-volume community pharmacy, the chance of a prescription error rises astronomically.

Many new pharmacists are far from humble about their newly minted abilities. I speak from experience: Pending passing of my state board and law exam, I bought myself a 1972 Corvette as a graduation present. It matched my attitude perfectly. I was downright brash about my skills. I was good, but nowhere near as good as I am today. Eighteen years of clinical experience have taught me as much as my education of my beloved Philadelphia College of Pharmacy and Science did.

As a rookie, I took my lumps. It took me about a week to have a misfilled prescription come back with my initials on it. It was humbling. It did however help me become a better pharmacist. I learned from every mistake I made.

Old Man Gower was the druggist (cringe) in Frank Capra's epic It's a Wonderful Life. Were it not for George Bailey, he would have killed a kid. Nobody wants to be Old Man Gower. I have woken out of a sound sleep realizing that I had drastically misfilled a prescription. I raced to work the next morning praying the Rx was still there. It was. It's not a mistake until it goes out.

Once, though, I did have a misfilled prescription go out. I had grabbed a bottle of oxycodone 30 mg tablets when I should have grabbed a bottle of 15s. Bad enough, but here is the kicker: The dose was 2 tablets q12h. Instead of getting 30 mg, the patient was now getting 60. I realized this that morning when I grabbed a prescription for oxycodone 15 mg and noticed that the tablet color was different.

Instantly an alarm went off in my mind: I had made a potentially lethal error. I raced to the phone and dialed the patient. Don't take a dose ... don't take a dose. She had already taken a dose. The home health nurse said the patient had end-stage cancer and was on high-dose opiates. She would keep an eye on things, but wasn't really worried.

I was. I figured that if the patient survived 6 hours, the nurse would be proved right. She was. I talked to the husband 6 hours and 30 seconds after the patient had taken the dose. (Deep breath.) She was alive, but he was not happy with me. I apologized from the very bottom of my soul.

The next morning I talked to the nurse. She said the dose did not faze her in the least. I, on the other hand, knew that I had gotten lucky.

I have a bit of advice for all of our new colleagues who may find themselves in a similar situation: If you make a mistake, own it! Take responsibility, admit your mistake, wholeheartedly apologize, and, for Pete's sake, don't try to cover it up! Protect yourself and fill out an incident report. Realize that you and your staff are human and a mistake can occur on ANY prescription.

I hope every pharmacist who reads this never makes another prescription error again, but they will. Handle it properly. Your patients deserve no less. Peace.

Jay Sochoka, BSPharm, RPh, obsesses over checking every prescription.