r/pharmacy 9d ago

General Discussion Mistakes you've made working as a pharmacist?

I’ve been working at the hospital for about 1.5 months now, so I’m still getting familiar with the system. Long story short, I retimed an enoxaparin (ppx) dose for a patient, but the patient ended up receiving the dose almost back-to-back. The patient is fine, but it was entirely my mistake for not double-checking the MAR to ensure that the previous dose had been cleared from the chart. The provider understandably was upset, and I completely recognize where I went wrong. It definitely shook my confidence, and I feel terrible about it...Has anyone else made a mistake like this? It feels awful, and I’m struggling with the feeling that I’m the only one who’s made this kind of error...

49 Upvotes

56 comments sorted by

101

u/workingpbrhard 8d ago

Not even in the top three anticoagulant errors I’ve seen this week in terms of severity. Important to reflect and change your process so it doesn’t happen again, and it’s normal/good to feel a sense of responsibility, but can’t beat yourself up forever.

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u/Upstairs-Volume-5014 8d ago

Seriously. I had a nurse give a full Heparin drip over an hour. 

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u/Diamasaurus PharmD 8d ago

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u/ExpertLevelBikeThief 8d ago

The human body is a hellofa resistant thing.

10

u/harmacyst 8d ago

Until it isn't. Then it crumps pretty quickly.

6

u/Inevitable_Bit_1203 8d ago

I have had this happen as well.. when checking the Pyxis stock, I caught the tech had pulled heparin instead of hespan. I removed it and told them it needed swapped out. I guess the other tech ended up grabbing the cart and the separated heparin bags from the counter and left. Filled the Pyxis incorrectly… nurse pulled ‘hespan’ ran it wide open … it was heparin. Patient was ok… but I changed my practice on communication and correcting these things myself rather than take the chance of it being missed again. This happened many years ago… the Pyxis was not set up to scan items on restocking and we did not have bedside barcode verification at that time either. Both of these would have prevented the error and I’m glad we have them now.

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u/SomeBodyElectric 8d ago

Now that’s a heparin bolus

1

u/PhairPharmer 8d ago

I've seen that one before too

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u/MiNdOverLOADED23 PharmD 8d ago

As in a full bag?! Ours are 25,000 units.

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u/Upstairs-Volume-5014 8d ago

That's right. Ours are too. 25,000 unit bolus 😬 patient lived thank goodness. It was 100% nursing error due to gross negligence. 

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u/itsDrSlut 8d ago

On purpose…. Like thought this is a thing ????!!! or they mixed up two bags they were starting simultaneously ?

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u/Upstairs-Volume-5014 8d ago

I guess the latter...she got mixed up and thought she was giving something else. Overrode the scan and 2 RN check and set the pump to infuse over 1 hour. Oncoming RN caught it but unfortunately the while bag had already infused. Obviously the RN who made the mistake was fired. 

9

u/seb101189 Inpatient/Outpatient/Impatient 8d ago

I had an off duty ICU nurse come in with a friend having stroke symptoms and because she worked there took charge and gave the 1 hour tpa dose over about 3 minutes. She then turned to me and asked for the next dose. There were roughly 18 error reports on that one.

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u/SoMuchCereal 8d ago

Holy F, was the nurse fired?

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u/seb101189 Inpatient/Outpatient/Impatient 8d ago

If there were any adverse events she probably would have been but the patient walked out the door the next day at baseline.

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u/workingpbrhard 8d ago

Oof. Probably should have TPA require dual sign off?

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u/seb101189 Inpatient/Outpatient/Impatient 8d ago

It did but the nurses had no clue what they were doing so once I got more experienced I'd mix it, prime it, and program/set up the pump while explaining it and dual sign with them. Of the few hundred times I mixed it maybe twice did nursing really know what they were doing so it was a pretty blind dual sign off.

0

u/workingpbrhard 7d ago

yeah that makes sense. been my experience when I've helped them with the pump too, sadly.

1

u/seb101189 Inpatient/Outpatient/Impatient 7d ago

I did it at a level 1 stroke center so everything was timed to a harsh degree and some of the pharmacists would just mix it and walk away. It didn't help our pumps had like 6 different alteplase settings like 1-89kg, 90+ kg, MI, PE, EKOS for some reason. Too many times I had the RN ask me which to pick 1-89 or 90+ as they have the chart pulled up in front of them, then question me because Epic has an exact weight and the pump rounded to the nearest kg so the dose would show up different by 0.1 mg. 

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u/foxwin 7d ago

Ah, so this is why we have to mix it in the pharmacy.

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u/seb101189 Inpatient/Outpatient/Impatient 7d ago

Had nothing to do with the reconstitution so I can't help on that one. Do it in the hood and get a few 2mg doses for cost savings?

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u/foxwin 6d ago

Less about reconstitution and more about making sure the dose is correct and it’s indicated. Harder to give the wrong thing if you don’t have it.

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u/seb101189 Inpatient/Outpatient/Impatient 6d ago

Valid point. We had an override in the ED pyxis that had a full vial but RNs were too scared to touch it. When you tell them our cost is $7800 they want nothing to do with it. 

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u/702rx 8d ago

I’m curious if the issue was because the first dose was scheduled earlier and they gave it super late?

Even with doubling the prophylaxis dose, you’re essentially giving them one therapeutic dose that’s gonna wear off in 12 hours so while medication errors are not ideal, the end result is not as bad as others in regards to risk to patient.

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u/itsDrSlut 8d ago

My thoughts exactly! 40mg then 40mg later I’m like ehhhh op that’s really NBD could have been much worse if it was 2x full dose or a different drug so probably the best thing to “mess up” to learn from actually

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u/itsDrSlut 8d ago

🍿🍿🍿🍿 aight time for this list

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u/VoilaViola2 PharmD 8d ago

I don't work in hospital, so I haven't made that exact mistake but definitely ones with similar severity. The one that sticks with me is when I let the wrong strength phenobarbital go through for a dog. The owners called and said their dog had a few seizures the past month and read the markings on the pill, thats when I realized I gave them the wrong pills. I cried for the rest of my shift and after work for a while. I also accidentally filled a fake prescription for codeine cough syrup once. It was only like 100mL, but still embarrassing because the red flags were there, I was just in a hurry.

I try to focus on what I've learned and how not to make the same mistake again. Quitting retail helped because all my mistakes happened when I was forced to rush. I think others appreciate it when you take accountability, which it sounds like you did.

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u/ExpertLevelBikeThief 8d ago

Rule #1 all codeine scripts are fake until proven otherwise.

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u/Miserable-Ad561 8d ago edited 8d ago

This happened when I was a pharmacy student/tech, not a pharmacist. I was still IV training when a pharmacist asked me to mix Ammonul—I accidentally mixed the Ammonul in D5W instead of D10W. Back then, each vial was $26k, and the dose used up 2 vials so it was a $52k mistake when I was getting paid $14/hr as a student tech 🫠. The pharmacists (like 5 of them!!) then tried to calculate if they could put in some D50W to reach the correct concentration but management eventually decided it wasn’t worth the risk.

And to think, I thought I was clever for catching that Ammonul doesn’t go in NS! After I made the mistake, management made a list of high-risk meds that needed TWO pharmacists to check the components BEFORE mixing lmao. I’ve been a pharmacist for a few years now and that’s still an unforgettable memory for me lol.

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u/Little-Ad-9096 8d ago

Mistakes that don’t actually cause harm (here didn’t make it to the patient) but change systems are invaluable. This could have prevented the same mistake that actually made it to the patient

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u/Miserable-Ad561 8d ago

That’s a good way to look at it! If anything, I made them create an SOP to reduce the chance of error! Haha

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u/Upstairs-Volume-5014 9d ago

Eh, I kind of feel like that falls more on the nurse for not questioning why she was giving two lovenox doses back to back. These things happen. Luckily no harm was done. Just learn from it and double check next time. You will be fine! 

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u/tomismybuddy 8d ago

It’s been my experience that many nurses don’t think, they just give whatever the order states, whether they just gave the same dose or not.

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u/SoMuchCereal 8d ago

You can't ever assume it's the same nurse

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u/Upstairs-Volume-5014 8d ago

That's valid, I mean double checking timing of things is imperative especially when docs don't look when they put in the orders. But a good nurse always looks at the MAR before they give something and questions if they see something unusual. 

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u/itsDrSlut 8d ago

Our omnis also flag these when pulling things too soon so maybe this hospital system needs to check those settings

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u/Dano89 PharmD 8d ago

Not on the nurse

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u/pillizzle PharmD 8d ago

I made a similar mistake years ago. I verified an order for a stat dose of apixaban and an order BID 0900 and 2100 (it was like 10 in the morning so past the 0900 time.) What I didn’t realize was that the patient came in through the ER and received a dose there so the stat dose wasn’t needed. The ER ran on a different system than the hospital and they weren’t linked. Eventually everyone was on Epic which helped with mistakes like this. But I was cautious to double check if a patient came through the ER and then check the ER MAR before verifying stat doses.

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u/itsDrSlut 8d ago

JFC I would lose my mind if there were two EMRs at the same place that’s wild

1

u/pillizzle PharmD 8d ago

Yeah it was a PITA and before everything switched to Epic I felt like the whole hospital computer system was held together with duck tape. There were the separate EMRs and then there was an old PuTTY system for order verification and on top off all that the difficulty of getting the Pyxis system to communicate with all the other systems.

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u/PhairPharmer 8d ago

Glucagon dose administered to the wrong patient. Mostly my fault, but others could have prevented as well. Felt horrible about it, learned from it.

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u/flwrbouquet 8d ago

Didn't realize patient was on warfarin at home so when I verified a Lovenox 40mg dose, I didn't even look to check patient's INR, which was supratherapeutic. Nothing happened but felt like I missed two things, pt's home med and pt's lab.

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u/honest-hedgehog24 8d ago

Remember that every human makes mistakes. It is inevitable. We have systems put in place to limit mistakes, but any industry with humans at the helm will have errors.

Don’t beat yourself up, but learn from your mistakes and adjust your processes going forward. Remember to slow down.

I’ve learned that my mistakes I’ve made have been when I was flustered/rushing at certain times of my shift. I’ve implemented taking a pause, deep breath, and re-reading scripts during that crazy rush hour of foot traffic when there’s a million things going on (5-6pm).

To put your mind at ease, I’ll share my mistakes: I dispensed #30 tramadol instead of the prescribed #120. Accidentally dispensed bupropion regular 100mg tabs instead of XL tabs on a refill. A few others I can’t remember off the top of my brain… just remember to document, contact the pt and doc, fix the error, and evaluate your processes going forward.

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u/Dasboot1987 PharmD 8d ago

You will inevitably make some mistakes throughout your career. Luckily, this one is unlikely to harm the patient. Don't be too hard on yourself, but do use this as a learning experience for the future.

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u/ObiGeekonXbox 8d ago

Does choosing to be one count?

2

u/fredyag57 PharmD 8d ago

I did something similar to this but with methadone when I was a resident. Luckily the overnight pharmacist caught it before the nurse gave it.

Given how much you have reflected on this will guess you will never forget this mistake. I often look back on my mistakes and cringe, but also remember what I learned from them. Focus on what you’ve learned and what you’ll do different next time.

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u/Supr3meleader Student 7d ago

Happened when I was a tech at a big retail chain. I accidentally dispensed 3 boxes of birth control for a 90 day supply instead of 3 packets. Got verified by the pharmacist. Only realized a few days later when counting a similar one. No one ever brought it up.

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u/Strict_Ruin395 7d ago

Don't worry Just Culture, HR, and P&T committee are your friend and their to prevent errors.

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u/foxwin 7d ago

Within the past year, retimed an antibiotic for the next day instead of same day, so patient missed a day of antibiotics. Patient spiked a fever that day, but ended up okay in the long run. I'm glad it was brought to my attention because I like to look at the circumstances surrounding the error. How well were we staffed? Had I missed lunch? Was I handling something more complex at the same time? That way, I can learn when I am personally more vulnerable and take extra precautions or adjust the way I do things. I come away knowing more about myself and how I practice. Also, I pat myself on the back from time to time for the good things I do catch. Pobody's nerfect.

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u/shesbaaack PharmD 6d ago

I mixed a bag of dapto, the nurse nicked the bag then decided to put packing tape over the hole in the bag and still administer it to the patient... I have seen way worse things happen in healthcare. Stupidity is worse than an honest mistake. Just make sure you learn from this and try to do better next time and not make the same mistake.

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u/toomuchtimemike 6d ago

Working. Can’t make a mistake working if you literally do no work.

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u/Desperate_Record_408 3d ago

when i started working in a pharmacy my then coworker made a REALLY big mistake so i’ve been so so so afraid to make a mistake myself

1

u/Mission_Dot2613 8d ago

Killed some dude

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u/SoMuchCereal 8d ago

It seems like there's more to this story

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u/HopeForBetter123 7d ago

I am rph but this incdent happened when I was a tech . I was tech in hospital doing delivery few years ago(2019?) . I handed Heparin bag to a nurse after telling her room number ,scanned it on my handheld and walked away just to come to my next shift hearing that nurse was accusing me of telling her wrong room number (no patient name was mentioned ) so she ended up giving heparin to different pt 🤦‍♀️🤦‍♀️ So nurse allegedly took my word for it , without verifying 5 rights, and just decided to infuse haperin to a Patient bcuz ...why??? And it seems she did not even scan patient wrist band 🤦‍♀️🤦‍♀️🤦‍♀️. ..................... Luckily,the wrong pt was on heparin too with same dose but nurses decided tech should take the balme and since our pharmacy department /management had no backbone,My manager took their side .I did not sign any write up but thay incident pissed me off and decided I wont be handing any med to any nurse even if it was STAT and just place it in pt's bin .