Pharmacy Error Reporting System Inadequate

The Register Guard (Eugene, OR), July 12, 2015 | Go to article overview

Pharmacy Error Reporting System Inadequate


Byline: Michael Smith For The Register-Guard

In the movie "It's a Wonderful Life," George Bailey prevented pharmacist Gower from mixing poison into a prescription. Gower's son had recently died, and Gower was preoccupied with his loss, not the prescription.

Did he want to err? Of course not. But he almost did.

Poison has always been present in pharmacies. It's called the wrong drug, the wrong dosage or an unintended inter action. Systems must become robust enough to make errors impossible, for people may be preoccupied, sleep- deprived, hurried, interrupted, multi tasking or under pressure to produce. None of us is immune from making errors. "Be more careful" isn't the solution.

Oregon is the only state where pharmacies are included in a confidential error reporting system. I was disappointed to learn, however, how few errors are reported with a full "root cause" analysis. The first pharmaceutical report was in 2012; last year we had only 28 reports from 721 pharmacies statewide.

I'm a retired physician, I take medications, and I have considerable knowledge of medical errors. I have been on both sides of the error divide. I regret my errors, but what bothered me in addition was that I could neither unburden myself of my guilt nor could I allow anybody to learn from my mistakes. Silence does not improve systems; it allows the same error to recur.

Hoping I might have something to offer, I contacted the Oregon Patient Safety Commission, whose staff were most kind to meet with me. I wasn't seeking employment, desiring only that my passion for improving medical quality and safety might allow me to contribute. I am willing to help in any possible way at any interested pharmacy or health care facility in the state. Reiterate: No charge.

Every person in my family has suffered from medical errors. This isn't surprising. Nor would I be surprised if every pharmacist who reads this knows that he or she has made errors or had close calls, and never reported them. Shame; fear of reprisal; no time; no harm, no foul - which one?

Sheer numbers of reports are less helpful than a few thoroughly investigated reports, asking why something occurred, then why that cause occurred, until the question can no longer be answered. The commission has people who can and want to help with this. I could, too.

However, the culture of medicine and management must both change, away from punishment, excuses, fear, shame, ridicule, silence and hiding, to one of openness, learning, sharing information and power, the goal being to improve systems to cause less harm. …

The rest of this article is only available to active members of Questia

Already a member? Log in now.

Notes for this article

Add a new note
If you are trying to select text to create highlights or citations, remember that you must now click or tap on the first word, and then click or tap on the last word.
One moment ...
Default project is now your active project.
Project items
Notes
Cite this article

Cited article

Style
Citations are available only to our active members.
Buy instant access to cite pages or passages in MLA 8, MLA 7, APA and Chicago citation styles.

(Einhorn, 1992, p. 25)

(Einhorn 25)

(Einhorn 25)

1. Lois J. Einhorn, Abraham Lincoln, the Orator: Penetrating the Lincoln Legend (Westport, CT: Greenwood Press, 1992), 25, http://www.questia.com/read/27419298.

Note: primary sources have slightly different requirements for citation. Please see these guidelines for more information.

Cited article

Pharmacy Error Reporting System Inadequate
Settings

Settings

Typeface
Text size Smaller Larger Reset View mode
Search within

Search within this article

Look up

Look up a word

  • Dictionary
  • Thesaurus
Please submit a word or phrase above.
Print this page

Print this page

Why can't I print more than one page at a time?

Help
Full screen
Items saved from this article
  • Highlights & Notes
  • Citations
Some of your highlights are legacy items.

Highlights saved before July 30, 2012 will not be displayed on their respective source pages.

You can easily re-create the highlights by opening the book page or article, selecting the text, and clicking “Highlight.”

matching results for page

    Questia reader help

    How to highlight and cite specific passages

    1. Click or tap the first word you want to select.
    2. Click or tap the last word you want to select, and you’ll see everything in between get selected.
    3. You’ll then get a menu of options like creating a highlight or a citation from that passage of text.

    OK, got it!

    Cited passage

    Style
    Citations are available only to our active members.
    Buy instant access to cite pages or passages in MLA 8, MLA 7, APA and Chicago citation styles.

    "Portraying himself as an honest, ordinary person helped Lincoln identify with his audiences." (Einhorn, 1992, p. 25).

    "Portraying himself as an honest, ordinary person helped Lincoln identify with his audiences." (Einhorn 25)

    "Portraying himself as an honest, ordinary person helped Lincoln identify with his audiences." (Einhorn 25)

    "Portraying himself as an honest, ordinary person helped Lincoln identify with his audiences."1

    1. Lois J. Einhorn, Abraham Lincoln, the Orator: Penetrating the Lincoln Legend (Westport, CT: Greenwood Press, 1992), 25, http://www.questia.com/read/27419298.

    Cited passage

    Thanks for trying Questia!

    Please continue trying out our research tools, but please note, full functionality is available only to our active members.

    Your work will be lost once you leave this Web page.

    Buy instant access to save your work.

    Already a member? Log in now.

    Search by... Author
    Show... All Results Primary Sources Peer-reviewed

    Oops!

    An unknown error has occurred. Please click the button below to reload the page. If the problem persists, please try again in a little while.