last refills

The pharmacy department is not a safe place for Sunday drivers. There will always be speed bumps as you cruise through a shift.  You will encounter some nasty turns that will force you to quickly alter your  filling process.  Along the way, the pharmacist will always have a choice of which direction to follow. Hopefully, these intersections are relatively safe, easy to maneuver, and just require a little common sense, so you can safely yield to unexpected requests.

Too often, I have met pharmacists moving through their day with an “I could lose my license” mentality. I’ve heard the phrase so many times, that it deserves it’s own billboard.  I understand where a pharmacist is going when they use this phrase. Unfortunately,  some pharmacists go there in situations that aren’t even close to being risky. I cannot imagine the board of pharmacy pulling me over, the next time I pop a few enalaprils into some one’s out of state prescription vial.  I am aware of the impact of what I do. There are times I have to be careful, but in a drug store, not every moment is a precious moment.  You will gain more mileage if you learn how to tell the major moments from the minor ones.

If you get stuck at every stop along the way, eventually you are going to find yourself in a pile-up of problems. The work will wreck you. In the long run, it’s not about managing stress. It is about managing time.  Every light is not red. You will wind up using most of your precious time. Time that you will need when you have to maneuver more tricky curves. You will be amazed at how easy it is to miss the dangerous passes. That is when your license will be in harm’s way. When lesser moments distract you, and you fail to notice what’s coming up your blind spot.

Five years ago, a tragic accident happened in a hospital NICU, involving a collision between an infant and a miscompounded TPN solution.[1]  TPN (total parenteral nutrition) is the most complex compound that will ever be prepared by a pharmacy. A TPN containing more than a dozen different ingredients is not unusual.  Very often the patient is an infant. Neonatal TPN should always be treated as high-risk.

The TPN order forms used in most hospitals try to make the process easier. I’ve seen some that are better than others, but often, they are inconsistent in the way they list ingredients because the form attempts to do so much. It tries to cover every nutritional need and variable, and it always lacks something.  In this case, a physician wanted to add zinc to a TPN, but the preprinted form did not list zinc.[2]  The doctor hand-wrote the zinc as 330mcg per 100ml, which was inconsistent with the format of the rest of the ingredients, which were ordered by the patient’s weight.

Hospitals have a deadline for when TPN orders must be written by; 4 p.m. is typical. It is common to miss the deadline.  In many cases, the physician is carefully considering the lab results, and providing their patients with perfectly tailored nutrition, but this practice ignores some risk. These orders need adequate time and the correct staffing to prepare them safely. In this particular case, the order didn’t start to get processed until 7pm, during a pharmacy shift less equipped to handle TPN.[3]

To compound these problems, the technician who normally was responsible for TPNs at the pharmacy, had called out sick that day.[4] This is why I am a big believer in cross training. I think that everyone should be trained and experienced on all the tasks in the pharmacy. They should rotate through these areas so they always remain proficient.  Too often, pharmacy departments are run like a collection of fiefdoms. So a pharmacist must beware of call outs. Especially if it’s one of the noble technicians.

From what I read of this incident, everything that happened after this point sounded like a journey through an obstacle course.  The pharmacy converted and recalculated some parts of the order to align all the ingredients in a consistent format. This got entered into one computer that profiled the order. Then it got entered into an automated compounder that made the order.[5]  A pharmacist manually performed these entries. There was no interface between the different hardware, and there were no barcodes to scan, that would have generated the order automatically.

The more times an order has to be transcribed from one place to the next, the more opportunities there are for errors.  In this case the mistake happened at the automated compounder. When it came time to enter the amount of zinc that should have been in the TPN, the pharmacist picked milligrams from the drop-down menu instead of micrograms.  This multiplied the desired amount of zinc by 1000 times. The mistake was missed by a second pharmacist who performed a verification check. A technician, who was newly trained on the equipment, was then left to compound the bag.[6]

Most neonatal TPN require a fraction of the zinc contained in the source container. The technician had to replace the zinc eleven times when compounding this mis-programmed TPN order. When she told the more experienced technician about it the next day, everything stopped in the pharmacy. They alerted the NICU about the mistake in the bag. The formula had been running into the infant since three that morning. The floor tried to rescue the patient with emergency chelation therapy, but it was too late.  The infant died and the cause of death was listed as cardiac failure caused by zinc intoxication.[7]

There were countless signs that something had gone wrong with the compounding process. Each one was missed.  There was the mistake made when milligrams were selected instead of micrograms at the beginning of this disaster.  Two pharmacists missed that.  Changing a source container eleven times during the compounding is a sure sign of a problem.  Later the technician would say she felt like something wasn’t correct, but was afraid to call it to the pharmacist’s attention. The nurses on the NICU inspected the compounding label before administration. But they only checked the numbers, not the units. And I don’t know how many people saw the actual bag of TPN that was delivered to the NICU, but that should have been a huge sign. Most likely, the bag was bigger than the actual patient. It contained a volume of 560ml, of which, 481.8ml was zinc solution.[8]

I am not simply pointing a finger at some other pharmacy personnel. I also have myself to give the finger to. About twenty-five years ago, I was newly licensed, and filling in for the regular pharmacist in a tiny drug store.  It was a weekend, and I was told it wasn’t supposed to be busy, but I had gone from zero to sixty prescriptions in less than 3 hours. Back then. pharmacy computers were no more than glorified label makers.  Workflow was tracked on a page from a loose-leaf notebook. I hesitated over each decision, and by noon, I had dug quite a little pothole for myself.

In the middle of these rushing-by hours, I was struggling to prepare a compound for a sick little boy with kidney disease.  It was a refill for his sodium bicarbonate solution that his mom usually ordered on a week-day. It had accidentally spilled at home and she was pressuring me to have it delivered as soon as possible. Even though it was a simple compound, it was the first time I had seen it, and the patient was a toddler.  I struggled to read the calculations that the owner had scribbled on the back of the hard copy. I gave up on his notes, and re-did the math on the loose-leaf paper page I had been using to control my workflow.

I grabbed a bottle of sodium bicarbonate powder from a shelf out on the floor.  At that time, it was sold along with the other over-the-counter preparations, so it wasn’t under the direct control of a pharmacist. The powder slightly fizzed when I added it to the distilled water.  As I worked, the mom kept phoning me for updates, the customers kept interrupting me with prescriptions, and the deliveryman kept threatening me that it was close to his quitting time. I cursed silently when the first bottle of the bicarbonate ran empty. My hand shook when I grabbed another source container from the same spot on the shelf.

I don’t know why I didn’t pay attention to the way the powder from the second bottle sounded when I added it to the water. I let the store deliveryman get to me, perhaps. His accusatory attitude, and impatient stare, made me feel like less of a pharmacist. I simply sped on forward to get him on the road. After he left the store with the kid’s bicarbonate solution, it quieted down a bit. I looked up at the blue apothecary jars in the store-front window and went over the directions I had just followed.

-“That second bottle really didn’t fizz when I added it to the water”, I thought.

I frantically picked up the second bottle and looked at the label. It had been a bottle of Boric Acid that I had just dumped into the little boy’s prescription. The bottle had been put where the sodium bicarbonate belonged, and it was out front, where it lacked supervision. I stopped everything in the pharmacy, ran out to the parking lot, and snatched the prescription  from the driver’s hands.

If you want to learn what effect this error would have had on my young, little kidney patient, just look up the toxicity of boric acid.  Although no one was harmed, it didn’t matter. I ignored an important sign, and put an innocent patient at risk. I can’t speak for the pharmacy that made the TPN error. I can make some pretty good guesses as to what could have possibly caused so many distractions that night. It sounds like there were huge gaps in their process control.  A lot may have changed in twenty-five years, but the failings of people still seemed the same. Unfortunately, this time, these failings caused an accident that stole the life of a poor little NICU baby.

Technology has improved so much since I was a young pharmacist, reading scribbled calculations on the back of a bicarbonate script. Bar coding, automated dispensing, and scanned prescription images are models of engineering that probably have prevented tons of human wreckage. We must continue to develop and use them. The rest of the change must come from the human operators.

Pharmacists must lead the pharmacy team. Avoid leading with your emotions. Don’t obsess over looking sharp. Stop worrying about your finish. Too often, we let time and pressure take the driver seat. Pause when you have to, and think about where you are heading. Learn to pick out the important moments as you shift. If you’re not sure what’s in your blind spot, park, and take a good look at every angle. Don’t respond to someone riding your ass. Tell them to back the truck up. And if you suspect that the whole damn vehicle is ready to skid off the freeway, get out of your ride. Organize everyone else in the commute and demand that some necessary repairs be made. It just might save a life. And protect someone’s license.