Beth Lofgren, PharmD, BCPS
Beth Lofgren, PharmD, BCPS
Beth Lofgren, PharmD, BCPS, received her PharmD degree from the University of Tennessee at Memphis in 1999, after completing a BS at the University of Tennessee at Martin. She started her pharmacy career in retail and has practiced in home health, long-term care, and hospital pharmacy. She has also been blogging as the Blonde Pharmacist since 2004, focusing on education for peers and provider status for pharmacists.

One Medication Error Can Make Clinicians Criminals

JANUARY 27, 2016
The thought of making an error that causes harm to a patient weighs heavily on my mind every single day. Each time I log into my computer, I pray that today is not the day I make a mistake that results in patient harm.
 
The reason I feel this way is because health care, in general, is not up to date with the latest and greatest technology.
 
Those who are not and have never been pharmacists make decisions based on the bottom line without giving those who are more concerned about patient harm a voice to ask for help. We work with less hours, and the rewards given to management for making cuts in staffing and shift coverage make the system more vulnerable to errors.

Where I work, the phone can ring 300 to 500 times a day, all while I’m attempting to focus on approving and entering orders. Coworkers interrupt one another in the middle of working up chemotherapy for a patient, and it can result in errors.
 
Because this is the norm, we have become oblivious to it, but I dread the day when all of this snowballs into something horrible. If we know that our work environment is unsafe, we should ask for better conditions.

Consider the case of Eric Cropp, who landed in jail after his approval of a chemotherapy solution containing more than 20 times the intended amount of saline resulted in the death of a 2-year-old patient. The pharmacy technician who mixed the solution bore no responsibility, even though she was distracted by personal wedding planning.

Also consider the case of nurse Julie Thao, who was charged with manslaughter in the death of a patient after giving her the wrong medication. She had worked a double shift with little sleep and made a human error that led to the mistake.
 
In Thao’s case, employees were rewarded for volunteering to help in shortages and other programs put in place for efficiency. It was cited that Thao did not use the barcode scanning system and was grossly negligent in not scanning; however, the system had only been in place for 2 weeks and the nurse hadn’t received all of the necessary training.

“While the law clearly allows for the criminal indictment of health care professionals who make harmful errors, despite no intent to cause harm, it will long be debated whether this course of action is fair, required, or even beneficial,” the Institute for Safe Medication Practices previously stated. “The fact remains that the greater good is better served by fixing the medication-use system issues that allow tragedies like this to happen. By focusing instead on the health care professionals involved in the error—the easy targets—one can easily avoid addressing inherent system problems.”

Systems that ensure patient safety need to be in place. We need reporting systems that are not only nonpunitive, but also mandatory.
 
In every single pharmacy job I have held, it was considered taboo to use this tool to report errors. If administrators don’t examine the data for system weaknesses and changes implanted, it is useless.
 
I would even venture to say that if every single pharmacist used his or her company’s reporting tool, most would find that their system is full of flaws and in need of major overhaul. Current reporting turns pharmacist against pharmacist and can even make a department look bad amongst the rest of the departments in a hospital.

We need better information systems in our pharmacies. I have used several different systems in my career and have not yet seen one that didn’t seem horribly dated with all kinds of flawed workarounds that can lead to even more errors.
 
Sure, the government can use incentive programs for electronic health record implementation and meaningful use, but how about looking at the systems we are using to force this to happen? We do not have high-functioning technology to achieve the goals of meaningful use. We force our current systems to meet goals, which results in a lack of new technology.

When there is a staffing shortage, there needs to be a plan in place immediately. Staff should not have to feel the pressure to speed up and weaken the system.
 
Whether that means slow down and notify patients and clinicians of the shortage immediately, or having PRN staff immediately available, staffing shortages should be met with the same urgency as any immediate need. Shortages set the stage for errors to happen.

Education also needs to be an important part of lending support to clinicians. Information should be readily available on how to handle every situation, and all processes should be outlined.

Pharmacists should be involved at the state level to give feedback to the Board of Pharmacy on what is happening in health care. There is strength in numbers.

Last but not least, pharmacists need to take it upon themselves to slow down in situations that become stressful. Speeding up at the urging of a nurse or patient (inpatient or outpatient) should be regarded as risky behavior that could be detrimental. Pharmacists have an obligation to slow down and not allow the pressures of nurses, patients, or prescribers to speed up a process that can potentially be fatal to a patient.

It is important to me that a patient gets the right medication at the right dose for the right indication. It is also important that we care about the pharmacists and other clinicians working to take care of the patients they serve at the system level.

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