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TEAMWORK IS NOT AN ABSTRACT IDEA In 2010, Alameda County Medical Center was fined $75,000 by the California Department of Public Health (DPH) for a preventable medication error which resulted in a patient's death. The patient, a female with end-stage renal disease requiring thrice-weekly hemodialysis, was admitted to the hospital for sudden shortness of breath and chest pain. During a dialysis session two days after admission, she experienced seizures, hypertension, and acute pulmonary edema necessitating transfer to the ICU. At 1400, shortly before transfer to the ICU her attending physician ordered 1000 mg phenytoin IV over 1 hour (specifically mentioning that the dose should not be "pushed quickly"). According to hospital records, the order was scanned to the pharmacy 45 minutes later. Because IV phenytoin was in the ICU's Pyxis unit, the pharmacy assumed the dose had already been given and took no action on the order.

Approximately 7 hours after…
THERE ARE EASIER WAYS FOR A PHARMACIST TO MAKE A LIVING
A young pharmacist decided to open up a small pharmacy inside a medical building.  He ran the pharmacy on a shoestring but was able to generate approximately 75 prescriptions per day in addition to a small but adequate over-the-counter business.  It was certainly enough to give shelter and feed his family of five.  One day, he was approached by two gentlemen purporting to represent a medical provider network.  They asked him if he would provide mail order prescription services to patients belonging to the network.  The arrangement would entail the network faxing or hand-delivering the prescriptions to the pharmacy along with relevant customer information and envelopes with pre-paid postage.  His instructions were to mail out the prescriptions within 48 hours of receipt and he would be reimbursed according to a fee schedule set up by the network.  Without performing any due diligence with regard to the network, the ph…
WHEN MONEY CHANGES HANDS, EVEN A WELL-MEANT GESTURE CAN BACKFIRE Fortunately, this doesn’t happen often but when it does, it has implications far beyond the actual misadventure.  Suffice it to say, it was quite an eye-opener for me as the consultant on the case.  A compounding pharmacy was presented with a prescription for chloroquine phosphate for a 7-year-old child who was traveling with her parents to Central America.  The pharmacist did not have enough drug on hand to compound the entire order and since it would take 48 to 72 hours to obtain it from his regular supplier, he contacted another compounding pharmacy in the area to see if they could help him out.  The owner of the second pharmacy noticed that he had two bottles on his shelf and offered to sell both of themat his cost and drop them off on his way home from work.  The pharmacist at the first pharmacy noticed that one of the bottles was sealed but the other one had an “X” on it, denoting that it had already been opened.  F…
WHEN IN DOUBT, CLARIFY
It’s amazing how something this small can snowball.  A pharmacy vendor for a long-term care facility received an order for potassium chloride (KCl) solution 10 mEq/15 mL with a dose of 10 mEq once daily.  KCl solution is commercially available only in a strength of 20 mEq/15 mL.  The pharmacy never clarified the order but instead, dispensed the 20 mEq/15 mL solution and labeled the bottle “10 mEq=7.5 mL”, which would have yielded the desired dose.  During their annual visit, the Department of Public Health noted the disconnect between what was written in the physician’s order section, the medication administration record, and what the pharmacy dispensed and labeled.  The good news was the disconnect did not result in patient harm because the correct dose was on the label.  The bad news was the error triggered an expanded investigation which uncovered numerous serious, possibly life-threatening, medication issues.   As a result, the facility receive…
A DIFFERENT TWIST ON CORRESPONDING RESPONSIBILITY

The biggest hot button legal issue in community pharmacy practice today is that of the “corresponding responsibility” of the pharmacist when vetting controlled substances prescriptions.  We all know what happens when pharmacists fill large numbers of prescriptions for controlled substances not issued for legitimate medical uses.  However, in my consulting practice, I sometimes get questions from pharmacists who are worried that they might be in big trouble if they reject a controlled substance prescription that later turns out to be legitimate.  Not to worry and here’s why… In a recent case in Northern Virginia, Davis v. Wal-Mart Stores East, a U.S. District Judge dismissed a series of claims against Wal-Mart and one of its pharmacists, Brenda Greer.  In this case, a former government contractor with a security clearance, Eve Davis, was receiving Adderall® for attention deficit/hyperactivity disorder (ADHD).  Because Ms. Davis did not ha…
THINK BEFORE YOU SPEAK
On the advice of her daughter’s psychiatrist, the mother of a severely mentally-disabled patient became her legal conservator for the purpose of managing her medications.  Knowing that her daughter didn’t drive and only had access to one pharmacy in the neighborhood, the mother went to that particular pharmacy requesting that her daughter be prevented from picking up her own prescriptions and instead, asked that all prescriptions be dispensed directly to the mother or one of her designees.  In order for the pharmacy to honor this type of request, it was necessary for the mother to furnish them with the conservatorship agreement.  This was done not once but three times in consecutive years and these instructions were ostensibly placed in the "notes" section of their computer system.  On several occasions when the mother visited the pharmacy, employees assured her that the request was in their computer system and that she had nothing to worr…