Discharge Scripts

Posted by The *Angriest* Pharmacist as Doctors, Errors, Lazy People, Me being a dick, True Story, Work Sucks

Do they even look at these damn things?

I have a hospital near me that generates discharge scripts via computer. It’s all based on what meds the patient was on during the stay in-house. I know the process there because I called and spoke with their pharmacist on duty one night. We hate our jobs equally.

It goes like this. The Ward Clerk generates a list of all current meds on the MAR (Medication Administration Record). This sheet includes PRNs, parenterals, orals, rectals — the works. The doctor then goes down the list and circles YES or NO. This sheet is then sent to the pharmacist who removes the NO drugs from the profile (by D/C’ing them). Then, the pharmacist prints these sheets directly on the floor and they are reviewed by the patient’s nurse based on what was said and what s/he expected. There is a space for the doctor to sign. My pharmacy will fill these w/o the docs signature because we deal with the hospital so much and these sheets are not “fake able.” I will admit though, that only 1 out of every 50 are unsigned. So, for the most part, the doctor has the OPPORTUNITY to review these sheets again. A quantity is written in on the bottom as well — usually it’s ONE MONTH.

So I can say, without a doubt then, that at least THREE sets of eyes see (or should see) these damn things before being given to a patient — Pharmacist, [Ward Clerk perhaps?], Nurse, and Doctor.

Why in the fuck did I get a sheet today that listed:
1. Fentanyl PCA 10mcg/hr Basal with 10mcg on Demand Every 10 Minutes.
2. D5NS 100mL/hr
3. Naloxone
- This was obviously in a ’set’ with the Fentanyl to pull from a Pyxis if needed.
4. Heparin Lock Flush 100 Units prn
5. Ancef 1g one hour pre-op

How did this shit get by? It was fucking signed by the doctor. He even wrote in *his* DEA number to cover the fentanyl…the only Narc on the script.

There was more on the script of course - they always leave OTC/PRN stuff and we just use our professional judgment on how to get those things to the patients (Ibuprofen, Docusate, Baby ASA). Usually we just grab it off the shelf if they want it.
But seriously? Dextrose in Normal Saline? Would you like me to educate the patient on how to start a line on himself? Should I also work through with him on how to operate the PCA Pump he has in his bedroom - making sure he sets it for MICROgrams rather than MILLIgrams since it’s fentanyl? [End Sarcasm]

I’m expected to review my work before it leaves my pharmacy. Why is this healthcare team not expected to do the same? I could get in serious trouble for not checking my final product prepared by my technicians.

If you care about the outcome I reached - I just scratched the bullshit out. Later in the night when it slowed down, I called the pharmacist on duty there and let him know that that stuff snuck through. He attributed it to “a student screwing around on the computer.” I attributed it to his laziness or lackadaisical demeanor. He did not like my analysis — nor did he apologize for the actions of himself or his student. If his lame-ass excuse was valid/true — it’s still his fault for not staring over the student’s shoulder…which would be the law for the student entering orders in my state of residence.

Child dies. Parents Perplexed

Posted by The *Angriest* Pharmacist as --Not Pharmacy--, Errors, Me being a dick, Stupid People, True Story

http://ap.google.com/article/ALeqM5gy_FocuLcPyslOqVeaOFan8yo7eQD8VM3A680

I just read this. I’m sure most of you all know about it by now - it seems like something that would hit massive airtime on the major networks. If you are religious, close your browser right now. If you think your feelings might be hurt by someone questioning your beliefs, close your browser right now. Last warning.

It’s painfully obvious that The Angriest Pharmacist is not a religious person by any stretch of the imagination. When I was a child, we attended a Methodist church. While in high school, we went to a Baptist (hellfire and brimstone) Church. My mother still goes there. I stopped the day I turned 18 — it was kind of an unspoken agreement between myself and my mother. I wish she’d stop going and come to her senses about the bullshit this guy spews. I wasn’t ever Baptized, but I consider myself to be affluent in the beliefs of the church and all opposing viewpoints. Let’s just say this, on my census form, I put Jedi.

These two parents, especially the mother, need to be jailed. At the very least, her three other children need to be put under protective custody. Why? She cost this little girl her life because she trusted her imaginary friend more than she trusted a doctor she could see, converse with, and touch. If this lady would have told the press she didn’t take her child to the doctor because Satan told her not to, we’d have her ass institutionalized. But, since it was attributed to God, and God is associated with light and goodness, it’s okay because her intentions were in the right place. What’s the difference?

Some of the worst fuckups in the history of mankind were based on good intentions and blind faith. If you need them pointed out, you’re a fucking fool.

I will admit that people have been dying of Diabetic Ketoacidosis for thousands of years. If this little girl would have been born in 1897 rather than 1997, she would have died in her home all the same. The family would have prayed, and she would have died…The issue here surrounds the fact that it’s 2008. Medical science has increased the life expectancy of a white female to nearly 80 years (which is far more than 11). But, the thing that solidifies that this bitch needs jailed is that several family members had been trying to get her to take the child to the hospital for days — and she prayed. Other’s common sense had taken hold over ‘faith’ — yet, mommy’s did not. Daddy’s did not. That’s because they are retarded.

A mother’s common sense — maternal instinct — has to exist…right? Nay — a HUMAN BEING’S COMMON SENSE must exist…right? A child is suffering from nausea, vomiting, excessive thirst, loss of appetite, and weakness for over a month and you do nothing but talk quietly to yourself and hope the child’s pancreas secretes more insulin? Did you get an answer? No. No one talked back to you. You sure as shit got a response.

I’ve heard people say that losing a child is the worst thing that can emotionally happen to a human being. In this case, I hope that’s true.

We did learn one truth — God does not replace Beta-Cells upon special request…maybe she needed a PA?

—–

Some might say to me, you are a faithless piece of shit, I’d kick your ass right now if I could find you. Actually, I’d bet most Christians would — Christians, at least from my neck of the woods are very violent. They’d attack/beat up an atheist just like they would a pedophile…They would beat a person with the very book that preaches (in part) about tolerance, hope, love and charity. Christians have been fighting and killing in the name of God for, well, about 2 thousand years now…I wouldn’t expect much change anytime soon. [Especially now that we have some new 'sins' to fight about!]

Anyway, I would challenge the above statement about myself. I am not without faith, hope, or love [tolerance of others? I'm working on it]. I hold that I have an abundance of all three. I have faith in my abilities, my Brothers, my significant other, the goodness of a stranger — just to name a few. I have unwaivering hope. I always hope for better–for others, myself, those in need/want. I have hope that the future is better than today. I hope that our children learn from our mistakes, and I have faith that we can raise them to meet that challenge. Love - one cannot work in the trenches without love. Love for the patient seeking counsel or the cancer patient seeking relief and comfort. Love for the person sleeping next to them each night. Yes, I have love…and it is the greatest of these.

You may call The Angriest Pharmacist an atheist, but I base my life and the way I live off of Christian teachings, morals, parables, and principles. I may be more Christian than some of the Christians reading this post…

I just question the existence of one more god than they do…

My Letter to the USA Today Journalists

Posted by The *Angriest* Pharmacist as Errors, Update

I decided to send a letter to the guys that wrote the recent string of USA Today Articles concerning misfills (with more to come) directing them to my recent post analyzing the numbers behind misfills - and showing that they are not as common as USA Today would like its readers to believe. Here’s what I sent:

To: Kevin McCoy (Journalist), Erik Brady (Journalist), and Brent Jones (Reader Editor)

Dear Mr. McCoy, Mr. Brady, and Mr. Jones,
I applaud your recent article in exposing the high-volume/low-staff environment many of our pharmacies nationwide are exposed to by their corporate counterparts. However, I think the problem presented may be drastically overstated. While even 1 error is drastic and 1 death is too many, the human element cannot be removed from pharmacy and therefore errors can never be eliminated…merely minimized.

Please take a look at a recent article I’ve written crunching the numbers on prescription drug misfills. The numbers in the article do an excellent job of putting the entire issue into perspective, and if presented this way, would relieve people that their pharmacies are, in fact, safe and not dangerous cesspools of misfills, incompetent workers, and careless pharmacists.

http://www.theangriestpharmacist.com/2008/02/26/the-real-numbers/
Thank you,
The *Angriest* Pharmacist
webmaster@theangriestpharmacist.com
http://www.theangriestpharmacist.com

Anyone else out there - feel free to forward the post URL to any news outlet you see fit. Direct them to “http://www.theangriestpharmacist.com/2008/02/26/the-real-numbers/” and give them my email address for further contact (webmaster@theangriestpharmacist.com). Let them know that we aren’t a bunch of misfits misfilling prescriptions and killing 5-year olds at will! The numbers don’t lie — only lawyers (and apparantly journalists) do.

The REAL Numbers — Updated 2-26-07!

Posted by The *Angriest* Pharmacist as Errors

Let’s analyze error rates. If you’re going to bitch about how big a deal it is, I’m gonna show you right here and now.

USA Today *says* there were ~3.7 million prescription errors in 2006. This is of course, a huge estimate. Data isn’t even available on the ISMP website. I remember reading, at some point, that the number was 1.5 million in 2007. That’s definitely not in line with what USA Today says. If the number I remember is correct, cut all the numbers I wrote below in HALF.

Projections for prescriptions filled each year range from 3 Billion in 2000 to 4 Billion in 2008 (but I’m not sure how reputable the Toledo Globe is). I’m sure it’s closer to 4 Billion if the 3 Billion number is correct - especially with the Baby Boomers now coming of age. I accept the fact we are comparing 2006 errors with projected 2008 numbers. Data is damn hard to find as there are so many companies and reporting of total fills as well as misfills are not required.

3,700,000 / 4,000,000,000 x 100 = 0.0925% of Rxs Misfilled Nationwide
0.0925 / 100 = 0.000925 Error Rate
4 Bill, Fills per yr / 59k Pcys in USA = 67,796 rx fills/pcy/year
67,796 rxs x 0.000925 Error Rate = 62.7 errors/pharmacy/year

-=+ ALTERNATIVELY +=-

67,796 rxs per pharmacy per year / 357 days per year = 189 rxs/day
(8 Holidays off)
189 rxs per day x 0.000925 Error Rate = 0.175 Errors/Pharmacy/Day

-=+=-

There you have it. 0.175 Misfills per day. That means I make one mistake every 5.7 days - I’d like to see any other profession compete with that number. Hell, most industries (food service) can’t handle 5.7 CUSTOMERS without fucking up an error.

Now - I don’t want to hear all this “1 error is too many” bullshit that you pansy asses would try and throw down our throats. That’s irrational. It’s impossible. There’s no such thing as perfection when you have human techs typing prescriptions for human pharmacists to check. (There’s an H-word in there making my point)

I think that some people need to realize the difference in quantity of Million and Billion. It’s not just a few letters apart. They also need to realize the quantity of scale we’re dealing with here.

Some people also need to realize that a misfill does not constitute something that WILL kill you. Sometimes, it something you won’t even notice! Granted, it’s still wrong/incorrect, but you still got the right drug, right dose, right regimen, and right quantity.

Here’s some common errors that would be reported as misfills that put the patient at no risk:
- Incorrect doctor on bottle (I can’t read a scribbled line, anyway. So…we guess — especially if it’s a resident or from an ER where you won’t be getting refills.)
- Incorrect Original Date (So you got it yesterday and I didn’t change the date. Do you care? Would you notice?)
- Quantity miscounted (So you got 31 instead of 30 or worse, 30 instead of 60. It’s easily fixed, if you got the short end of the stick, but it’s a misfill nonetheless.)
- Drug changed and quantity increased and you found out (So, I changed your Lisinopril 40mg to 2 tablets of the Lisinopril 20mg. Sue me. This may not be classified as a misfill, but irrational people may construe it as such.)
- Your name is spelled wrong. The word “daily” is misfilled as “daiyl” - Some other typo occurred that was negligible and a person with any sense could understand that it was a typo and not going to kill them.
- The tech/pharmacist fails to put an applicable auxilary label on the bottle and you get a belly ache for not eating with your Biaxin XL.
- You got a child-safe cap when you requested an easy open (this ones a stretch, but I’m making a point that just because the pharmacy did something wrong - it doesn’t mean someone is going to die)

The above miniscule errors are the VAST majority of “misfills,” in my opinion.

Note: My errors and numbers are purely speculative and have no scientific bearing. They also do not take into account any error made in a hospital by any member of a hospital staff (unless filling scripts as retail I would assume). Those would be considered “medication errors” or “order errors” and not “prescription errors.” The difference is that the hospital order is for RIGHT NOW, and the prescription is for a length of period while not under hospital care.

More Numbers:
3.7 Million Errors / 200,000 Pharmacists = 18.5 Errors/Pharmacist/Year
4 Billion Scripts / 200,000 Pharmacists = 20,000 prescriptions/pharmacist

That means each of us fills 20,000 prescriptions per year (thanks for pullin’ yer weight boys!) and makes 18.5 errors out of those TWENTY THOUSAND OPPORTUNITIES. Alex Rodriguez would be so lucky for a fielding rate that high…[For those not following the math, that's an error rate of -- you guessed it -- 0.000925 or 0.0925% and a success rate of 99.9075%]

If, let’s say 3,000 of those people that got a misfilled prescription error DIED as a DIRECT result and not due to poor health - do you realize how miniscule that number is? NASA would launch with an chance of failure that slim…

BTW - The chances of YOU getting a misfilled prescription leading DIRECTLY to YOUR DEATH is 3000 deaths due to misfills/4 Billion Prescriptions Filled! That figures to:

0.000075%

So, I ask you this — how many errors do you make in a year’s time?

-=+=-

What are your odds of getting hit by lightning? 1/700,000 (in the year 2000)
Number of people struck in 2000? 400
Number of people struck in 2008 (proj. for pop 300 million): 429

Odds of winning the grand prize for Powerball? 1/146,107,962

1/1081 scripts are misfilled
1/700,000 people get hit by lightning
1/1,000,000 people die from 300-mile car trips (per US DoT)
1/1,333,333 scripts filled leading to death because of a misfill
1/146,107,962 lines played will win Powerball Grand Prize

So, I ask you this — Have you bought your Powerball tickets and stood under a tree during a storm today? Or, are you sitting at home in fear that your pharmacist may kill you?

Okay I Screwed Up

Posted by The *Angriest* Pharmacist as Education, Errors, Me being a dick, True Story

I was discussing the USA Today Article with a local insurance salesman yesterday. We were talking about the ramifications of the article for pharmacy, insurance companies, and patients. I also gave him my take on the article and how increased volume (not decreased volume as Walgreens would tell you) inherently leads to more prescription errors. I then explained the error that lead to the child’s premature puberty and the infant that was given five-times the acceptable dose of Amoxicillin (which I doubt the whole “writhing in pain” statement - UPDATE: The Angry Pharmacist Debunked this).

The salesman and I parted company and a lady that was standing behind him in line approached to pick up a prescription. She said, “Hi. I’m here to pick up my infants Amoxicillin prescription.”

“Oh my gosh - I’m so sorry! I wasn’t intending to scare you or anything.”
“It’s okay. My stomach is up in my throat right now.”
“You have nothing to worry about. Our dispensing system has several places where quality control checks are made. Our computer checks all doses and drugs for interactions, and every prescription is personally verified by a state-licensed pharmacist.”
“How do you know and error is not made?”
“Well, when the human element is incorporated into any process, we can never be 100% sure that errors are not made, but pharmacy and especially pharmacists pride themselves on perfection. I treat every prescription like I’m filling it for my own child’s use.” [No kids yet - but she smiled]
“Would you check it again to be sure?”
“Absolutely. That’s my job.” [I went and checked it all again: verified the handwritten script, the dose, allergies, etc.]
“Everything looks great. Ya know, the article we were talking about was exploring the premise of high volume leading to prescription errors. The infant that got the incorrect dose of Amoxicillin was filled in a CVS that filled more than 400 prescriptions that day.”
“Oh yeah? How many have you filled today?”
“About 75 — and we close in about an hour. We’ll be lucky to fill 80.”
[I then proceeded to give the most personalized counseling session ever. 'Shake it up. Keep it in the fridge. Dispense 2.5 mL twice a day - morning and evening. Here's the line for 2.5 mL and you can keep this syringe. Be sure to give this for 10 days only then pitch the rest. You shouldn't notice any problems. If a rash develops, call the doctor's office. If the baby develops any stomach problems, try giving the dose after feeding her. Do you have any questions for me?']

I felt about 3 inches tall. I was shaken. I now vow to never talk about anything edgy to non-pharmacy staff again. I should’ve known better. I was trying to put down CVS and WAG to the salesman, but I failed - extremely.

Anyone else had a situation similar to this? Eating crow for breakfast, lunch, and dinner? I’m still full from my meal.