A look at one pharmacists unwanted potential

A recent post by John Poikonen got me thinking about medication errors. They’re part of every pharmacists day, but we rarely give them much thought.

I’ve been a pharmacist for more than 10 years now and I’ve make my fair share of mistakes. I would like to think that none of those errors caused harm, but that would be naïve to say the least. And forget about the errors that were never detected because one can only speculate about those.

During my early years of staffing I entered anywhere from 300-400 orders per shift; more with overtime, extremely busy days, etc. Assuming that I was 99.9% accurate, which is a ridiculous assumption, let’s do a little math.

– 300 orders per shift x 4 shifts/wk x 50 weeks/year (hey, everyone gets a vacation) = 60,000 orders entered annually

– With 99.9% accuracy, don’t laugh, that means I committed approximately 60 errors per year. Now I know that accuracy rate is a crazy estimate. I’d believe 60 errors per week, but 60 errors per year, c’mon.

– Anyway, assume 60 errors annually for 10 years = 600 medication errors that reached a patient

– Based on numbers from various sources I’m going to assume that a majority of these errors were harmless. Using similar sources I’m also going to assume that approximately 3% of my errors inflicted damage in one form or another. That means I managed to harm approximately 18 patients during a ten year span in my career. How many of those 18 patients were seriously harmed or even killed secondary to one of those mistakes? We’ll never know.

For those pharmacists that think they don’t make mistakes, think again. There is zero chance that you won’t harm a patient during your career. If you’re fortunate you’ll never know. If you’re unfortunate you have the potential to be fired, lose your license, or end up in prison like Eric Cropp. So much for just culture.

We don’t mean to make mistakes. No one rolls out of bed and says “hey, today it’s my turn to make an error”. By definition an error is unintentional (from Merriam-Webster an error is “an act involving an unintentional deviation from … accuracy“) and everyone makes them. So how do we eliminate them? We can’t because they’re unintentional or weren’t you listening. As long as humans are involved in the process there will be mistakes. And I don’t believe that you can remove humans from the practice of pharmacy because in certain circumstances you need insight and experience that no amount of automation can emulate, yet.

We can, however find ways to reduce errors. I firmly believe that technologies like CPOE, BCMA, CDS, robotics, or some yet to be developed system will prove beneficial in reducing medication related errors, but they will never completely eliminate them. I also believe that diligence and exploration into ways to incorporate new dispensing techniques, better practice models, evidence based practice and workflow modeling can help reduce pharmacy related errors as well. It’s silly to think that technology is the only solution.

There you have it; something I neither wished for nor desire to keep, but remains nonetheless. Just a thought.