At the risk of oversharing, I wanted to recount a personal experience that says something about the pressures that pharmacy professionals are under and the challenges of meeting standards in these conditions.
For the past several months I have been taking the same medication. The original prescription was in 5 mg tablets, which I take multiples of. Over the months, I have been tapering my dose.
My local pharmacy is always very busy. They offer a range of services as well as extensive retail. It doesn’t matter what time of day or evening I go; I can see that the pharmacy team is working at 200%.
Recently, I went for a refill. A few days later, I opened the new bottle and counted out the tablets. I was about to swallow them when something struck me as odd. Luckily, I was wearing my glasses. The tablets looked the same. But were they smaller? I pulled out the old bottle and compared the tablets. Yes. The new ones seemed smaller. So, I looked at the label on the bottle – the bottle which otherwise looked identical to all the bottles that I had received from the same pharmacy over the proceeding months. Sure enough, these tablets were 1 mg. I had nearly underdosed by a magnitude of 5.
I was lucky enough to notice the difference, but my pharmacy did not help protect me from error. Someone ought to have reviewed my past prescriptions, noticed the difference, and brought it to my attention. Right? I think I can understand why that didn’t happen. Between the frantic pace at which all staff are working and the relative insignificance of the prescription change, it’s a ball that was easy to drop. But if I were a different patient on a different medication, it could have resulted in a very bad outcome indeed.
Patient Safety Week is October 24-28. I’ve spoken to you before about the challenges you face in maintaining standards in an environment that demands you provide more services with diminishing resources and sometimes even under the fear of violence. I know that your first priority is patient care, or you would not be working so hard under such difficult conditions. Please take this as a friendly reminder that the little things continue to matter and to keep a watchful eye.
We’ll be bringing more information and reminders about Patient Safety Week this month.