No one likes to talk about errors, medication errors or incidents. It’s a taboo topic for some. But we are trying to change the culture around medication errors.  We know that errors are made not because we want to make them but because there are often factors and processes that contribute to them. And by analysing and studying them up close and personal, we may be able to identify the root cause and hopefully come up with some solutions to minimize future errors.

I completely agree. But when the error involves myself unable to correctly check that drug A is indeed drug A but not drug B… how else can you explain the error that doesn’t identify yourself as the “risk factor” involved? How do you come up with a solution to address this “risk factor” without taking it personally?

Many years ago, I was one of the pharmacists involved in a medication error -a PCA pump for morphine was dispensed instead of PCA pump containing hydromorphone. The steps to dispensing a Patient controlled analgesia (PCA) pump are complex and long. But each step serves a specific purpose from ensuring the entries are entered correctly into the computer, to checking calculation for the infusion parameters such as rate, concentration and volume, to the verification of the final product when it is made. This last step is the most important step; yet this is where I have failed so miserably that day. I have failed to catch the error – we have picked the wrong drug.

My supervisor didn’t give me a hard time. It was her job to review any medication incidents with each pharmacist, to review the procedures, to understand the reasons, to make sure we learned the lesson. But I had to internalize what had happened, needed to go back to the exact moment of when the error occurred and figured out why and how I made this error. Without doing this honestly in my head, I wouldn’t know why I made that error. So I do take my errors personally, at least during my own root cause analysis. Once I have figured out the cause or reason, I make damn sure it doesn’t happen again and move on.

So taking our errors personally is important. Without confronting them honestly, we will never learn how to prevent them in the future.  But once we have learned the lesson, then don’t beat yourself over the error. It would be wise to move on and don’t take it personally anymore.

 

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