Interview Story - Crisis Resolution

It was a picture-perfect Saturday and I had some self-indulgent plans… and then the on-call phone range. It was my weekend for the specialty home-infusion pharmacy where I was employed. On the other end of the phone was a very anxious nurse who was at the home of a patient that she had scheduled an infusion.

She informed me that she was about to set up the infusion. When she looked at the label to check the elements on the label, she noted the patient’s name did not match her patient. I told the nurse I would have a courier pick up the medication and deliver the correct medication but I would need to conduct an investigation and this would take time. I asked her to reschedule the infusion and I would return her call upon the conclusion of my investigation. She agreed.

The situation became more urgent as I deduced, that if Patient A had a medication that belonged to Patient B, then the opposite was probably true. I hung up the phone and immediately called Patient B. His wife informed me that he was at work. She asked if something was wrong.

I didn’t want to alarm her, but I needed to know if Patient B had received and more importantly, had been infused with Patient A’s medication. I asked her to check the refrigerator as the patient’s infusion was a two-day infusion and there should be a drug in the home. She checked and confirmed my greatest fear, the patient had received the wrong medication and half of it had already been infused. The stakes had just gone up exponentially.

I contacted the husband immediately. We discussed the error. He explained that he and the nurse had become so familiar with each other and the process, that she allowed him to set up the medication and the infusion site such that when she arrived, she would simply start the IV and monitor his infusion while he slept. I told him I would have a driver pick up the remaining bag of medication, deliver the correct medication for his next infusion. I asked him to keep a record of any unusual side effects and call me immediately if any were to occur. I told him I would reach out to him MD to report the mistake to see how he would like us to proceed. I would then follow up with him with the results.

I called Patient B’s MD to inform him of the error. The drug was basically the same; the dose infused, however, was more than his normal dose. The MD and I agreed that the patient would be infused less of his drug on day two of his infusion to give him the correct cumulative dose over his two-day infusion.

I called Patient B and explained to him the nature of the error and how we would resolve it. We took full responsibility for the error, as the nurse was an employee of ours as well. It was not an easy resolve as the RN who had become so endeared by the patient was removed from the case and terminated. What should have been a shipping error resulted in a possible life-threatening scenario.

On Monday morning upon opening, I gathered the production team for a meeting. I informed them of the incident that occurred over the weekend. We recreated the environment in which the error occurred and I performed a root cause analysis. Once we determined the cause of the error, we re-introduced our policy of “pick one-pack one” and recommitted to adhering strictly to the policy that was already in place to avoid causing harm to the patients that we vow to provide care to.

Patient B was very understanding and thankful for the straightforwardness and honesty in handling the situation. His MD was also very grateful for my immediate intervention and resolution which prevented potential harm to a patient and a potentially costly lawsuit.