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near miss

The Power of the Pen

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Power of the PenEver since my very first day on the job as a hospital pharmacist, I have placed a “C” using a blue Sharpie on every single label that I have ever checked.

While the “C” stands for Chuck, there’s no good explanation as to why this seemingly insignificant little marker chose me. I guess the first time I ever checked a prescription, I picked up a blue Sharpie.  Ever since that day, it is the only pen I would ever use.

Power of the Pen

Many of us who work in pharmacy have certainly considered the positive impact that we have on patients and fellow healthcare providers. In fact, most of us became pharmacists first and foremost because we wanted to help people.

I believe there are many of us that have not considered the tremendous power that the simple act of putting pen to paper can actually have.

I know that over the years my “C” has been placed on prescriptions that helped a patient recover from an illness or helped a NICU baby beat the odds. I know that my initial has done a lot of good.

I trust that my “C” has never done a patient harm. None of us in this profession would ever want to think of that possibility. The fact is that when you experience a “Near Miss”, as I have, it makes you look a lot closer, double check your work, and then check it again. It can also be pause to examine what is really important in your career and your life. For me, it became the driving force for the development of RxTOOLKIT and this blog. I want to ensure we do everything within our power to increase education and automation, as well as utilize the best technologies out there, so that we can ultimately save lives.

In the post I have written about my experience “My Near Miss”, we posted a survey asking, “Have you ever caught a “near miss” that could have caused patient harm?” 100% of respondents to our survey answered that they have had a near miss, 66.7% have actually had more than one! Click here to read the post and take the survey for yourself.

Obsession

Over time, I became rather obsessive and superstitious about the blue Sharpie. I would go to great lengths to be sure I always had the blue Sharpie with me. My secretary always keeps a box of extras hidden in a secret location known only to the two of us. The pharmacy techs I work with always keep extras around just in case I misplace my own. Even when the hospital wouldn’t order them for me, I began purchasing them out of my own pocket.

The Sharpie and the blue “C” became intertwined with my professional identity. Every script and label that crossed my path would receive the same exact treatment and became clearly identifiable as having crossed my path. Techs are always able to trace orders back to me. Once a pharmacy tech was double-checking a medication dose I had initialed. Something seemed wrong to him and he brought it back to me. Once verified, it was determined to be an incorrect dose—My Near Miss. Another time, I had checked a script of two Metroprolol 50mg and one 25mg tablet and initialed it as correct. Another pharmacist came to me to verify if it was accurate. In fact, it was meant to be three Metroprolol 25mg. Two close calls! Thankfully they were quickly identified and directly returned to me for verification before administration.

I even began receiving the markers as gifts! One of our pharmacy technicians once brought me a new “retractable” blue Sharpie. Another time, I received a miniature size blue Sharpie. Another pharmacist at my hospital even began to copy my behavior, but instead using a blue Sharpie to mark “J” for Jason.

Over time, the blue Sharpie unsuspectingly became an intrinsic part of who I am, a trusted partner, full of power and possibility.

Reflection

Until I recently began to reflect on my career and accomplishments, I hadn’t ever truly acknowledged the power of the pen. In fact in the 40 years I have spent as a pharmacist, I never thought much about my compulsive behavior until I heard Eric Cropp’s Story and had a chance to get to know him.

When I heard Eric’s Story for the first time, my immediate thought was, “My “C” on the wrong label, could do a patient harm (my worst fear) and also take away my career, my profession, and my life.”

I love this profession. Even at this time in my life, with the majority of my career years behind me, I still love what I do each and every day.  My heart will truly ache when the day comes that I have to put my blue Sharpie down for the last time.

Many of us who work in pharmacy, can clearly remember the errors and mistakes we have made. Some will be forever etched into our minds. It can be easy to let these events overshadow all of the successful actions we have taken, dispensing the correct dose, time after time.

This blue Sharpie and the power within, has taken on a deeper level of respect and importance to me. I am just as careful as I have always been, but I have now grown to consciously acknowledge the intrinsic power of the pen.

Medication Errors “A Pharmacist’s Tale” — John Karwoski, RPh, MBA

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MEDICATION ERRORS
“A Pharmacist’s Tale”

I was working at the hospital last night and caught a “near-miss… The physician ordered a 4000 unit bolus dose of heparin. The technician prepared and brought me the 4 mL labeled syringe along with the vial of heparin to check. I realized the vial he used was a concentration of 10,000 units per mL. This syringe contained 40,000 units of heparin, enough probably to kill this 70 some year old patient. I showed the “new” technician, a young college student looking to go to medical school and follow in his father’s footsteps. He prepared the correct dose and we sent it up. I was still thinking about the error I caught later that evening and went over to the technician and explained to him how I made an error as a young pharmacist, mixing up the wrong dose of a chemo drug and how it brought me back to an old pharmacist lesson, “READ LABELS 3 TIMES”. I told him I still do this today and that it works. He was grateful to me for the suggestion.

I could not sleep that night thinking of that “near-miss”. When it happened I wanted to show my supervisor but the other staff said that he would just get him in trouble. Errors should not have that type of repercussion. We should learn from errors and everyone should be encouraged to bring forth errors or potential errors. As a consultant, I have reviewed numerous medication errors at surgery centers thru the years and have tried to offer suggestions to prevent future errors. I have a few ideas to think about:

1. READ LABELS 3 TIMES: once when you pick up the drug, once when you prepare the drug and once before you administer the drug.
2. If you treat pediatric patients, I would implement a policy that a second nurse check all medications prior to administration. And please tell your staff they must read everything on the label.
3. A few drugs found in ASCs should be handled more carefully. First, if you stock concentrated KCl vials, remove them from the facility! You do not need them and if your Anesthesiologist questions you have them call me. If all else fails, you can purchase KCL riders already diluted.
4. KCL isn’t the only concentrated electrolyte. 23.9% sodium Chloride and magnesium Sulfate vials must also be further diluted prior to administration. My recommendation is to place these drug vials in binss or plastic bags wherever they are stored and label them in BIG letters: “STOP: MUST BE DILUTED BEFORE ADMINISTRATION” You can also store these drugs away from other drugs and even as far as keeping them in the director’s office where you would have to ask for a vial.(don’t forget about the Anestheia carts where I see Mag sulfate vials occasionally. And mag sulfate is also on some crash carts which is OK if labeled correctly.)
5. Another drug on some ASC formularies is 0.75% bupivicaine (Marcaine, Sensorcaine). Bupivicanine toxicity is very dangerous and this strength can cause toxicity a lot quicker then the 0.25% or 0.5%. Have your intralipid protocol attached to the lipids IV bag or bottle.
6. Review your formulary for high risk drugs, sound alike look alike drugs, visit ISMP to find out more about what drugs can be dangerous, talk to you consultant pharmacist and develop policies on safe handling of these drugs.
7. Promote error reporting from your staff and don’t forget, “near-misses” because I didn’t and it saved someone’s life.

John Karwoski, RPh, MBA
President and Founder
JDJ Consulting, LLC

My Near Miss

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About 6 years ago I was working as the IV pharmacist on second shift and I was presented with a large number of IV’s to check prior to delivery.

The IV delivery to the nursing units was already late and I felt the pressure to get the IV’s checked as fast as possible. I was checking the lot of IV’s at a speed that I thought safe.

I checked one IV for D5W 1,000 mL with 50 mEq of Sodium Bicarbonate. As I checked it, I put my initial on the label and then moved on to the next IV. Something, and I don’t know what, caused me to stop and re-look at that IV one more time. I checked everything again and suddenly realized that the technician had injected 50 mL of Potassium Acetate 2 mEq / mL in the bag instead of 50 mL of Sodium Bicarbonate.

It is still difficult today to articulate how I felt at that moment. I was very close to physical illness. I don’t know what happened to make me look at that IV again, but I am so thankful that I did. I think about that incident whenever I think about Eric Cropp’s story.

I am fortunate to work in a hospital that has shown it lives by a just culture. I have witnessed personally how they have approached incidents and they do all they can for the patient, the family, and the caregiver.

Eric wasn’t so lucky. I know him and I know how difficult it is for him to live with the consequences of the error. I admire him so much for doing all he can to help the rest of us in our practice environments.

Please share your near miss with our readers. It helps to tell the story and it helps the healing process. It can also help the rest of us prevent it from happening to our patients. Report events through ISMP-MERPS to help protect your colleagues and their patients.

At the very least, please take our survey and stop back often to see what stories are being told.

We are all in the healthcare profession to help our neighbor.; certainly none of us wants to do any harm.

Hopefully by sharing our stories, we can help each other and bring awareness to prevention.