Hurricane Jill

Two kinds of pharmacists

This post was written March 13, 2009 at 0437. I was working nights as a pharmacist at a small local hospital in Seattle while going through the Match for the second time.

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There was a med error recently at Outside Hospital. I was involved only tangentially, having received a phone call about the fact that a particular patient’s meds hadn’t shown up on her pre-printed medication administration record, when the order had been faxed down to us on the previous shift. My standard way of dealing with a call like that is to look on the patient’s profile and see if we’ve entered them. If we have, we try and sort out whey they didn’t show up on the MAR.

Sometimes it’s just a communication delay between my system and the one that prints out the MAR.

Sometimes it’s because the regimen has an extra-long dosing interval, and the person on our end entered it in such way that it won’t show up until the day that next dose is due. In that case, I fix it so it shows up on the MAR but also shows that no dose is due that day.

But most often the order is simply not entered at all. In which case, I ask them to fax me the order. I don’t accept secondhand verbal orders unless it involves a situation where the small delay involved in writing it down and faxing it to me would affect patient outcome. Which is the correct and legal way to practice in a hospital setting. There was somewhat of a learning curve at this hospital about this particular practice, but it only takes one miscommunicated order to make the point. So I will only enter a verbal order in a hospital setting if it comes from the prescriber him- or herself. In which case, I’m going to be writing it myself, so by definition it’s going to say the same thing as what I’m entering on the profile.

Conversely, there are some things I will attend to urgently even if they are not ordered that way. First doses of IV antibiotics for any patient, or an initial pressor or sedative drip for an ICU patient. Things like that, where rapid treatment can significant improve outcomes. And I have no problem telling a nurse that if she has orders for both an octreotide and a PPI drip on a patient who’s been admitted for an acute GI bleed, and doesn’t have enough lines to give them both at the same time, she needs to do whatever is necessary to get another line started, because simply not giving one of them is not an acceptable solution to the problem. And if she doesn’t want to take my word for it, she is welcome to call the attending right now at 2am and ask which one she should hold, because that decision is outside her scope of practice.

These kinds of things are exactly why I went to school for seven years, have an alphabet soup after my name, and get paid a lot. I can also start that IV, if necessary, but that’s outside my scope of practice.

So that’s my process. Things get triaged according to their effect on patient outcomes. It’s not that I’m uninterested in customer service, it’s just that my customer is the patient, not the nurse or the doctor. But I work fast, so in reality I rarely have to triage order entry to any significant extent. Usually by the time the nurse has paged me to let me know about an urgent order, I’ve already entered it. The tricky part of my job is triaging my technician’s work, to get things made and delivered in the appropriate time frame for whatever’s going on with that patient. There are basically five drug distribution processes in this pharmacy:

1) Point-of-care inventory management (i.e. Pyxis loading and restocking)
2) Normal batch production and delivery
3) Exception processing (drips and first doses)
4) Stop what you’re doing and get this drug to the patient within 10 minutes
5) I go to the bedside and dispense meds/make drips out of the crash cart/pull stuff from the Pyxis to be entered and charged later.

My tech does 1-3, and will prepare the meds for #4 which I then deliver. I deliver because when I’m hanging around waiting to take the meds up, it makes a stronger point about how quickly I want it done. And my tech has two speeds: steady and thorough, and slightly faster than that. Whereas I’m either working super fast, or goofing off. We get similar amounts of work done, but she always looks like she’s working hard, and I usually look like I’m not.

So the other night I got a call about meds that weren’t on the MAR. They hadn’t been entered, so I asked the nurse to fax them to me, which she did. The entire med list was composed of wacky meds and doses, so I entered the ones that looked reasonable, and checked the patient’s past admissions and ER visits for information about the others. Not getting any good answers, I went upstairs and wrote an order to hold the meds in question pending clarification.

Unfortunately, that’s really all I remember clearly about it. But apparently when the order was sent down previously, all the meds were entered on another patient’s profile, and on top of that, one order was entered for a look-alike, sound-alike drug with a totally different use and mechanism of action, which unfortunately is not a benign thing to give a patient who doesn’t need it. And the patient got it, resulting in an event that prolonged hospitalization. Of course, it didn’t help matters that the nurse had misspelled the drug name on the order form, which made it even more easily mistaken for the other drug. In addition, the dosages for the two drugs have exactly a tenfold difference, making it even more difficult to determine whether it was the dose that was written in error, or the drug name.

Given those facts, it would be reasonable to ask, why didn’t I make that mistake when I got that same order? Mostly experience, I think, with a generous helping of pharmaceutical fascism. Part of the reason I looked at the ER records was to help me figure out which one of the two possible medications the patient was actually taking. The other drugs on the list gave no clue about which diagnosis was more likely, and given all the other mistakes, I was pretty sure the nurse who’d filled it out had no idea, either. But this level of carefulness is not any sort of practice standard. It’s just that I don’t enter things that don’t make sense to me, and this patient’s home meds simply didn’t.

In any event, the pharmacist who did enter the order is a new graduate, and probably will not sleep well or practice confidently for some time to come. It’s a horrible feeling, the first time you make a big mistake like that. Really any time, because hopefully it’s not so frequent that you ever become blase about it. But the first time is the worst. You just want to go hide somewhere and never practice pharmacy again. And you’re convinced that no one else has ever made such a horrendous mistake, ever.

But most pharmacists have. As one of my preceptors said to me back when I was a pharmacy intern, There are only two kinds of pharmacists out there: those who have made a mistake, and those who will. Anyone who says otherwise is either lying to you, or lying to themselves.