Pharmacy Incident Report Example: Fill & Download for Free

I rushed into a patient’s room and asked my preceptee (who was in his final shifts of his 12-week preceptorship) “you didn’t give that Lovenox yet, did you?” He raised his hand up from her abdomen, empty syringe in hand, and proudly announced that he just administered it. This was in the morning, within an hour of getting report on our 6 patients, and we were under pressure to hurry and give meds to this particular patient so she could go to surgery. ….Yep. Surgery.Needless to say, I had to report the med error to my facility, the surgical team, and the patient. The surgery had to be postponed for another day. It came along with all the shame and guilt you can imagine.There is a 6th Right: Right Reason. Every med must be considered for appropriateness by the nurse. Just because it was ordered by a physician, approved and provided by pharmacy, and scans in without flagging any warnings from our EMR systems, our critical thinking while serving as the last line in the med admin process VERY often catches near-mistakes. It is exceptionally rare (if ever) that a nurse makes it through a shift without challenging legitimately the appropriateness of one or more meds on the list of dozens of meds they are assigned and expected to administer. There are many potential weak spots leading to this. For example, the ordering physicians to think ahead and discontinue inappropriate meds for the patients’ upcoming treatments. Sometimes this is just due to having multiple physicians on the case, and the left hand doesn’t know what the right hand is doing. In this case, for example, the attending physician ordered the standard Lovenox daily for DVT prevention, but the surgical team scheduled the patient for surgery, the patient was scheduled for surgery but pharmacy doesn’t check for such things and the EMR system is also not associated with this detail, so there it is: the lovenox is Ordered, Approved, Provided, and on the Scheduled Med list on EMR. Some other examples of such disjointedness that is 99.9% only caught by the astute nurses’ critical thinking skills (using the 6th Right): meds that will be dialyzed out, PO meds for newly NPO patients, standardly ordered meds despite symptoms making those meds contraindicated (i.e. stool softeners for a patient with diarrhea), and let’s not forget that sometimes we are trying to provide patients with the meds they would have taken at home but they were unable to provide accurate info to begin with so they end up being given our best guess at what is the intended med and dose of their fill-in-the-blank med.Another common reason is that in healthcare, the only constant is change. A real pet-peeve of mine on Cerner and/or paper charting specifically is not being flagged that an order has changed. For example, I see on the EMR my patient is scheduled to get antibiotic A in a few minutes. I obtain the med, which is dispensed to me. I scan it and administer it, only to catch later that just prior to admin of antibiotic A, a physician ordered that A should be discontinued and antibiotic B should be given instead. The time lag before pharmacy reviewed it and Cerner and paper charting are infamously incapable of effectively alerting us to this new order in real time. Another thing about Cerner and paper orders are that these formats make orders VERY easy to miss. After my current job, I will not work for another facility with either of these unsafe systems. A “med error” I got written up for was that I missed an order to give a Gatorade to an NPO patient an hour before her surgery (now I’ve learned that this surgeon carb loads PO prior to his surgeries). I didn’t see the Gatorade order because it was visually lost to me in the several dozen same-font, cluttered and disorganized listing of orders, not to mention it contradicts the surgeon’s NPO order AND wasn’t looking for such an order because it was so unusual. That was the first Gatorade order I’d ever had in my nearly 14 years of nursing. So, now I’m bitter about the write-up, grossly frustrated and disappointed in the ordering system, and highly anxious about the huge potential for more serious mistakes (and anxiety and other negative feelings makes a human even more prone to making a mistake). It is, indeed, maddening.Punitive work cultures, communication issues between humans, and information system failures to alert the nurse of real-time results can also lead to med errors. I reported myself mid-shift when I realized I missed a normal-valued lab result that I had no idea was even drawn (thinking from the prior nurses’ report that it was a lab not due until near the end of my shift). I should have responded to this lab result with a very sight adjustment in a drip. I informed the patient, the physician, my charge nurse, and my facility via an incident report of the self-caught error. I’m confident had I not caught it myself that no one else would have, either, and according to my colleagues “should have just kept my mouth shut about it.” Ethically, I felt obligated to hold myself accountable, but I got written up for this med error. This further increases my anxiety about the potential for making errors and my resentment at having to work with an info system that has much to be desired in the prevention of med errors. We are asked, and indeed expected, to write incident reports on all deviations from the norm of care so the system can identify patterns they might be able to prevent in the future, but with a punitive culture (and having so much documentation required already that we are lucky to be able to clock out “on time”) …it’s just unrealistic to think all errors and near-misses are even documented.Being late with a med is a med error. This is very common, though, for any number of reasons. During med pass, patients will need help to the bathroom, food/drink needs, calls for unscheduled meds they need urgently, family members and patients have questions to be answered, the meds you are supposed to give are not prepared yet or simply can’t be located, unusual vital signs and lab results need to be called to the doctor, and the list goes on and on…. And there you are, nearly every shift something will be given late to someone. Bam! …Med error.An easy “trap” to try your darnedest to avoid is drawing up the correct dose a partial med (pill that must be split with a device, partial IV med vial…) while also administering a multitude of other meds AND while being almost constantly interrupted. Good luck with never making an error with odd doses in the midst of the turbulence of med passes on a busy hospital floor. Keep in mind, too that we are performing all this multitasking and critical thinking in a noisy, socially exposed environment, listen out for safety concerns, and have to pleasantly smile while adhering to every policy in all we do.The last example I’d like to mention is common: the nurse takes all the steps to set up the primary and secondary lines to administer an IV med as a secondary, but the clamp is closed. Of note, I can’t think of a nurse that hasn’t experienced this med error at some point.Not one physician, pharmacist, EMR system designer, or nurse wants to have any part of a med error. In fact, the extreme anxiety of the potential to make errors and the shame and guilt when errors are made contribute greatly to the woes of our professional community. I don’t see true resolution to widespread, common med errors until and unless we create and implement systems/technologies which allow crystal clear communication between all professional disciplines involved in actual real-time.In order to survive with your sanity intact, learn from the mistakes of others, be as proactive as possible about reviewing orders over, and over, and over again, learn about your physicians’ particularities, ask tons of questions of the more seasoned nurses around you, learn about coping skills such as mindfulness to be able to face the fact that there will be times you will unintentionally make mistakes, form the best habits possible to minimize your risks of making mistakes (watch that your IV med is actually dripping so you know that clamp is open), and listen to your patients! They will help you more than any EMR or electronic ordering system with checking the 6 Rights. If they are questioning the reason for a med, then you should pay special attention to questioning it, too.

I had an unfortunate error where this happened. It was about closing time and two people dropped of new scripts about 10 minutes til closing.My technician was closing down the registers and so I had to both enter and fill each script. Since I was the one doing it, I grabbed both bottles off the shelf at the same time, counted 30 of each and poured them into unlabeled script bottles.By the time I had them counted, the labels were coming off the printer and I attached the label to each bottle, separated the paperwork, and stapled the bag shut.Since I was the one who took the scripts originally, I took the time then to counsel on the script then instead of after the script was filled. Plus, it was closing time and I didn’t want to mess around with extra steps if I could avoid it.Anyway, the bottom line is that, I had put the right pills in the wrong bottle. So person A got B’s pills, person B got A’s pills.About 3 days later, the husband of patient A, called to say his wife was acting funny and wanted to verify the pills. I was the one who took the call and immediately realized my error. So not only did I mess up that script I messed up the other one too. I still had to make that call and tell them they had the wrong stuff.So what happened. Well, the husband brought back the wife’s script. He was clearly pissed about the situation. I have no choice but to apologize over and again, but essentially the damage is done. This was fairly early in my career and I think the husbands main goal was to remind me how much trust the public puts in me to do a good job. His point was, if you want to make this right, don’t ever let it happen again. Of course I refunded his money and gave him the correct script at no charge and that was pretty much the end of it. Yes, I had to file an incident report that an error was made. These types of errors are extremely unfortunate when they happen, but the incident report is a tool we can use to “tighten up the ship”.The other script. I called the lady who received the other script that was wrong, but she didn’t know it. I was glad she took the news well. I explained what happened and with that information, she brought back the wrong script, and I gave her the correct script in its place. I of course refunded her money and gave her the correct script at no charge. I wrote a second incident report for that error also.Before the whole internet world jumps on me about how this could have ended up far worse believe me I know, probably better than anyone how much worse it could have been. Ironically both scripts were for sleep aids and neither drug did any damage to the other person so to speak. It depends on how you perceive damage to a person, but from an overall life damaging perspective this did nothing to either person. If anything, we all learned a lesson to pay better attention both as a pharmacist and as patient that’s putting stuff in their bodies.Both labels had a description of what the pill should look like, so, if a person was really being cautious, they could have caught my error long before they took a pill. I’m not saying therefore I’m not guilty. I am, I made a mistake. I am also human, and so is your personal pharmacist who has made mistakes also.So that’s my example of what happens when a patient gets a script in error.

This one : The Callousness of India’s COVID-19 ResponseWritten for The Atlantic by a Ms. Vidya Krishnan (we will get back to her later), it just shows how journalism is truly failing with each passing day.The article is just a rant, an outlet for the hatred the author harbors against the current Indian administration. In writing about the lockdown and the Indian government response to it, the author somehow manages to start off by talking about the CAA and NRC protests in India in Jan. I have no idea how that was relevant to the article, but the author did.The country reported its first case on January 30, but authorities steadfastly insisted that cases were one-offs and no local transmission was taking place.I have ZERO clue what the author is trying to say here.Yes, India did have its first case on Jan 30, a student who returned from Wuhan. There were 2 more cases in Feb. And that was it. At the start of March, India still had 3 cases, all imported. By definition, they were one-off, and there was no LOCAL transmission, leave alone COMMUNITY transmission.Even today, India thankfully hasn’t reached the community transmission stage — WHO corrects report, says no community transmission in India. WHO has rectified its earlier statement and said that India has “clusters” of cases but no community transmission. And we all know that one incident, the Tablighi Jamaat congregation in Nizamuddin is responsible for the former — Coronavirus: 1,445 cases liked to Tablighi Jamaat event, total crosses 4,000But instead of condemning that incident, the author twists it to suit her agenda; for her, calling out the TJ is just another form of persecution of Muslims in India.The health min has been sidelined, with Modi, in his characteristic way by centralising the response.The govt is hiding a pandemic in plain sight, & has painted a target on the backs of an already persecuted Muslim minorityI report for @thecaravanindiahttps://t.co/Dwpb6ZKqAb— Vidya (@VidyaKrishnan) April 6, 2020She then lambasts the government for the short notice and laments that there were no shops open after the announcement.Modi made his speech at 8:00 p.m. on March 24, saying the restrictions would come into force just after midnight and be in place for three weeks. By the time he spoke, shops had closed for the day, catching off guard people who had been repeatedly told not to panic-buy. The next morning, nothing was open in Goa, the state where I live. Elsewhere, such as in Britain, France, and Italy, grocery stores and pharmacies have remained open to provide essential services, but here, they are closed.I live in Mumbai, and all essential stores are open. Medical stores are also selling basic groceries and fresh produce. This is literally what the PM had said — no need to panic, essentials will be available. But it seems like asking for a little patience was too much as the author could not wait even a couple of days.She goes on to highlight the “authorities’ callousness” by quoting a few incidents.Again, the authorities’ callousness has been on display: In one heartbreaking video that went viral, police in the northern state of Uttar Pradesh force young boys to perform frog jumps as punishment for violating the curfew. Another video shows police waiting outside a mosque in the southern state of Karnataka, beating worshippers with a stick as they leave. Similar cases of police brutality have been reported around the country, and social media have filled with messages of people running out of food yet afraid to leave their dwellings, fearful of the police.So, the case where offenders who broke lockdown guidelines were made to do “frog jumps” is “heartbreaking”. And the fact that people congregated for prayers despite clear directions not to do so is not criticized but police meting out punishment is?It’s absolutely insane that someone like her is afforded multiple global platforms to spread the misinformation and channel her own biases.Today, she mocked the PM for wearing a face mask for a virtual meeting with all CMs to decide on extension of the lockdown.Ah, wearing a facemask for a zoom meeting.Sums up India's COVID response, which is high on tokenism & low on common sense to a T. https://t.co/iHBIdxjRJ2— Vidya (@VidyaKrishnan) April 11, 2020India’s COVID response, as per her, is “high on tokenism & low on common sense”. She forgot that the PM is a role model for crores of Indians, and his wearing a mask in a virtual meeting would set a great example for the rest of the nation. His words, his actions, his appeals have power. And we have already seen it when he asked people to clap for the first responders and the medical workers a couple of weeks back. We saw it again when he asked everyone to shut off their lights and India’s power consumption went down by more than a quarter.Electric power consumption dropped an average of 26.6% around India last night during @narendramodi's call for Indians to switch off their lights at 9pm in solidarity with COVID-19 victims. (@Reuters graphic) pic.twitter.com/5D6cQnO5Ce— Dr. John Barentine FRAS (@JohnBarentine) April 6, 2020So yes, he needs to wear a mask even for online meetings. It is an example for people to be followed. Not to mention, the fact that his residence will have other people too.India has the most stringent response to the COVID crisis.With nothing more to say, the lady compared the PM to Lord Voldemort, exposing the vacuousness of her own arguments.Having said that, I like not having to see Voldemort's face. I hope this is a permanent change.— Vidya (@VidyaKrishnan) April 11, 2020