I look back at my own medication training many years ago and recall how we were drilled day in and day out for months and months to ensure we adopted the correct procedure in how to dispense the wide range of medication people required.
The regime we went through was so demanding we all lived in fear of ever making a mistake, not only because it was more than our job was worth but also the fear of damaging another person through our own mistake. In fact it is fair to say medication errors didn't exist.
I have noticed over the years that generally people don't seem to have the same fear of making a medication dispensing error. Discussing the issues recently with some young people it was horrifying to hear how they thought I was being fussy in reiterating the enormous responsibility there is in dispensing medication to other people. As our discussion went on it became apparent they didn't realise how even everyday mediation purchased in a pharmacy or even a supermarket actually does affect a person’s life; so few of them realise that a healthy person taking an overdose of an everyday drug could result in them losing a limb, or even worse their life.
Having nursed a number of people including family members during serious illnesses I have always fully adhered to strict medication dispensing procedures. I know it is so easy even for the most professional and experienced amongst us to make a simple mistake and how dangerous one mistake can be.
Just how easily and innocently simple errors can happen was recently reinforced to me in my own practice when dispensing medication to my own dog. On return from the animal hospital I lined up my dog’s medications on the bottom shelf of my medication cupboard ready for the dose first thing the next day.
Mid-morning the next day I froze when I saw my dog seemed to be in greater pain and I suddenly realised I had forgotten to include one of his tablets in his Breakfast a couple of hours earlier. I quickly rectified the situation and seriously told myself off, writing a note to ensure I didn't make the same mistake the next day.
The note worked and sure enough when I was preparing his next breakfast I remembered each medication he needed. The only problem was I couldn't find one of the medicines. It transpired after searching high and low that I had put it in a different cupboard as my mind had been more focused on the mistake I had made and not on following the proper procedure.
This whole scenario really brought it home to me how important following a set procedure is, to ensure you remember not only how to dispense unfamiliar medication correctly and on time, but also to ensure your focus is maintained on the task at hand and not be distracted.
You see I wasn't familiar with the medication or the dispensing method for a dog, even though I had been shown by the vet. I had given some of the medication but not all of it as I hadn't written down what needed to be taken and when. Because it was a dog I didn't follow my training, instead I had relied on myself remembering the different items needed. Then once I realised my error I focused so hard on making sure I didn't make the same mistake again I didn't put the medication back in the correct place.
For years I have been proficient in dispensing medication and yet I made this simple mistake when I came across an unfamiliar situation and I got distracted. Please take heed Dispensing of any Medication is not a mere routine but a serious Responsibility