Made a silly mistake today. A new pt was being discharged with palliative meds. Completely missed that the buprenorphine (butrans) directions were incorrect. Had been Rxed as every 3 days, rather than every 7. Wouldn’t have caused harm, but not right

I really beat myself about mistakes (I think it’s the nature of the job). So wanted to tweet it out to try and help. I think it happened for lots of different reasons, as is also the nature of errors. 1) there were other errors with the discharge (and inpt chart) which I spotted

Haloperidol has been prescribed without a frequency. On the inpatient side some wacky oramorph prescribing had happened. And when the real CD prescription actually arrived the doctor had asked for 9 of the butrans patches, which caught my eye more than the directions. I had

Checked the BNF as this was new for the patient. But again, the frequency didn’t catch my eye.
2) this patient wasn’t going home today, but I don’t work wednesdays. I prioritised the other 5/6 TTOs that were going today as well as juggling the stock requests and a

Manic screening slot. 3) due to the volume of work I had I did not take the whole of my lunch break. I knew I needed to get the TTOs done as well as dealing with some important queries. I came back to work after 20-25mins. 4) although this pt wasn’t going today I don’t work weds

But I didn’t want to leave this to be done in the morning. I don’t like to leave things behind if I can help it. Also with the current state, they are getting pts out very early in the morning if they can, so I wasn’t sure if there would be time tomorrow. I did it last at around

4:30-4:45. Again completely missed it. 4) today marks 3 years since Mum’s cardiac arrest. So obviously that’s been on my mind all day.

Luckily a senior pharmacist checked it once it had been dispensed and raised it with me. I spoke to a Dr, he said cons had

Requested it to be every 72 hours. But that 7 days made sense and we should change it to that. I was very lucky to catch the dr in the stairwell as he leaving.
Learning points:
- said it before, but I really need to prioritise breaks

- ask for help. Lots of TTOs late in the day for the same day or early the next morning is stressful. And takes time. Rushing things leads to errors
- buprenorphine is a minefield. There are so many different formulations, so I need to take care when screening these prescriptions

I know errors = learning. I also change something in my practice when things happen. Currently, all my mistakes have been minor (wouldn’t have caused any harm). But important to reflect.

Thanks to anyone that actually read all of that #pharmacy