I was the bad guy

Many years ago, I worked as a home care pharmacist, responsible for dispensing parenteral medications for patients who required to continue their therapies at the comfort of their homes. Many of them were being treated with infections that required long-term antibiotics such as diabetic foot infection or osteomyelitis.  

One day, we had an unusual request to dispense IV pentamidine. We didn’t normally have access to this specialized medication but it was a special request from a local respirologist. He wanted his patient to receive IV pentamidine at his home for his pneuomcystic Jirovecii pneumonia – an opportunistic infection common in an immunocompromised individual but rare for an otherwise healthy individual.

It wasn’t easy to procure the drug but the respirologist begged the hospital to release sufficient supply to our pharmacy. After sorting out few logistical challenges, we took on the request.

But everything went wrong.  

The drug was delivered to the wrong place, given to the wrong patient and so the medication that was specially procured for this actual patient has vanished.  It was a shipping incident but nonetheless, the pharmacist needed to inform the physician of the incident and I was the lucky person on that day.

So I put on a brave face to speak to the respirologist. I paged him through locating at the hospital. I waited and waited and there he was, connected on the phone.

I remember I had rehearsed in my head  many times how to explain to him about the incident. It didn’t matter how I explained the sequence of events, the contributing factors of the incident and any relevant details – the bottom line was, we screwed up big time and we let him down.  To say he was furious was an understatement.

I understood why he was mad. He had the right to be mad. But after the incident, I thought about why no one in the shipping department came forward to talk to me, to explain about the incident and to offer an apology.  When I attempted to talk to someone in the shipping department, it felt like everyone wanted to hide in a corner and avoided me.

I didn’t mind being the bad guy. But when a serious incident like this happened, fear and avoidance were the two obstacles that would not help us to move forward with resolution.

We are humans; we make mistakes but when we don’t have the courage to face our mistakes and deal with them, then that’s the ultimate mistake that will bring humanity down.


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My name is Cynthia Leung and I am a practicing pharmacist in Kingston Ontario, Canada. This blog is for me to share my ideas, opinions and perspectives on how medications are used in our health care system. Note that these posts are my own opinions and do not represent the opinions of my current or former employers and / or organizations that I may belong to. Any possible case scenarios described in my posts would be modified to maintain patient confidentiality. This blog is not a platform for professional advise for patients or health care providers and the content is not meant to support any clinical decisions or replace professional opinions. Also the images are either taken or created by the author, or adapted with permissions. I hope you will enjoy reading my posts!

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