Mistakes
Saturday, October 4, 2008
The November before I registered in Pharmacy, I was stocktaking my dispensary and an item that comes in two strengths only wasn't right. Our typical stockholding was one of each, I remembered dispensing one strength earlier that day. But that strength was still on the shelf...
Something that strikes fear into any medical practitioner are Errors and Mistakes. In their worst form, Mistakes can kill people. Mistakes can end your career. In their gentlest form, a Mistake saps your confidence and brings self-doubt raining down on your every clinical decision.
On the Medical/Doctoring front, I'm yet to make a mistake. This is because I've not yet had one iota of responsibility in this setting. Comparatively, in Pharmacy I have made mistakes. From a purely mathematical point of view, it would be nigh on impossible that I haven't. Today, I'm going to discuss a some of my 'errors', and how they fit into the context of both medical and pharmacy practice.
My first error of the dispensing kind was aged 12. I was organising a basketball team, and I'd typed out a phone list and distributed copies to all the kids in the team, so we could find out who was playing each week. Unfortunately, despite being captain, I was never contacted. I had unwittingly swopped the last two digits of my phone number on every sheet. I guess I didn't read my own number, if I read it at all!
Basic 1: No matter how familiar something is, check it every time. Don't rush; do it once, do it right.
The first thing I did was to pull out all the paper work on the patient. It wasn't a very busy pharmacy, and I knew the patient by name and face. I told my boss, found the phone book, and gave her a call...
More recently, I was due to attend a mate's Birthday Dinner after work. I was planning on swinging in for a full ten minutes before crashing out at home, as I was working a marathone weekend. I'd spoken to the guy a few days earlier, and he'd sent me a text with the restaurant's details; King of Kings. I parked in the Valley, and strolled to Chinatown. I looked inside and couldn't see any of my friends. I phoned him to discover that he and the crew were at King of Kings in the City - about 15 minutes away. I went home to bed, quietly pretty cranky at myself.
Basic 2: Communication between pharmacists, pharmacy staff, doctors and patients is essential in reducing mistakes.
Mrs Watson answered the phone. Thank goodness she was at home. I asked if she had the box with her, and she says, "Yes, yes, it's right here." I checked which strength it was; the wrong one. "Okay, don't take any." I asked if she was going out in the afternoon; she wasn't. I explain that I need to get the medication somehow...
A few years ago, I lived a pretty slovenly flat, in which the cooking was quite sporadic. One night, my flatmate cooked a delicious Thai Green curry. Yum! After the meal, the dishes accumulated as they always do; about two weeks later someone decides to do the dishes. Lastly, the dishwasher gets to my rice cooker and reveals a pungent green mess of mould, rice and some sort of orange fetid water. There was gagging. It was stuffed. I had seen the rice cooker there for all that time. I'd even thought, "I should clean it up." But, hey, it wasn't my turn. Someone else would do it.
Basic 3: Failure to act is a mistake, and will end badly. Watchful waiting is not a failure to act. Know when to stop watching and when to do something.
Basic 4: Make time to listen to your patients. They might tell you something life saving, if you just give them the chance. When they do, have your ears and eyes open.I started the delivery car and headed to her place. The atmosphere was thick and eerily still. I was dripping with Queensland sweat. I flew up the stairs and knocked. "Come in, lovey." She cooed. Her apartment felt musty and boiling. "It's on the table." I saw the guilty box, and put it in my pocket. "Here's the new one, sorry about that." "That's okay, lovey, I was going to say something about the different colour box, but you were looking a bit busy"...
The three non-pharmacy incidents I've mentioned merely annoyed me. I felt dumb for making a silly mistake, but I knew that it wasn't anything more. I may have even looked stupid. Whatever. But a mistake that potentially causes physical harm and/or loss of life, that's a different story. Whilst the majority of pharmacy mistakes aren't clinically significant, when your job is to make sure errors don't happen at all, it results in a bit more self-reflection.
I got back to the pharmacy and stood in front of the air conditioning. Whew. Crisis averted. I continued with my stocktake. Stocktaking felt safe. I found a few more discrepancies, all of which could be accounted for. I knew, because I meticulously checked the records...
My preceptor was understanding; he too had fouled up. Badly. We talked about having confidence in your ability. I was good at my job, he reassured me. Deep down, I knew that was the case. A few days later, my confidence was back. A few weeks later, I registered.
