Pharmacists make dispensing errors consistently closer to the end of a 12 hour shift then in the morning. The most serious error I have ever made was on the label of a prescription for Dexamyl Spansules. This was in 1966. The product was a diet “pill” manufactured by Smith Klein & French. It was a Spansule, a sustained release product designed for once a day use, in the morning. The ingedients were 15 mg of Dextro-amphetamine Sulfate and 3o mg of amobarbital to “take the edge off”.
I came to work that day at 8:00 AM and my day ended at 10:00 PM. Fourteen hours with no uninterrupted meal breaks or rest breaks. The prescription was presented at around 9:00 PM, thirteen hours after I came in to work.
Of course, I knew that the Sig was “One capsule once a day”. Still, being well compromised, tired and hungry, I, inexplicably, put “One capsule FOUR times a day” on the label.
Three days later, the patient’s husband came in with the bottle. “What the hell is this stuff?” he demanded. “My wife can’t sleep. She is up all night doing hippie love dances to loud music in the living room. Last night she was dancing topless with the shades on the windows wide open. The music is so loud that a neighbor called the police. What the hell did the doctor give her?”
My heart sank and my stomach churned when I looked at the label. I had to tell this guy what I had done. I can confidently state that that error was 90% due to my being exhausted. I am a careful and competent pharmacist now and I was attentive in 1966.
We must present our argument in such a compelling manner that the members of the fifty state boards of pharmacy are forced to take action.
The chain drug store companies won’t make changes unilaterally. They would perceive giving the pharmacists any concessions a competitive disadvantage. However, I don’t see much argument if they are all forced to obey pharmacy laws. The wait for the chains to act on their own would be long and drawn out.
Changes will come at rocket speed if a patient has a story of getting errors in their prescription because the pharmacist was tired. Urge your patients to tell their stories.
The pharmacy boards do not care about your lousy working conditions. They are mandated to regulate the profession of pharmacy in a manner that prevents danger to the public. They boards have been looking the other way for decades. They are NOT doing their job. The boards must be compelled to step up and do the right thing.
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