I do not pursue these types of studies academically, so I am sure I am going to offend someone who does. But I think this needs to be said.

There is not now, nor will there ever be, an error-free human system or process. As a pharmacist with 35 years of management experience, I have dealt with employee prescription errors for a long time in the real world of community practice. And here is how I have chosen to frame them:

    1. It happened

    A certain percentage of prescription errors fall into this category. No one can really tell why, but something happened and an error was made. These kinds of errors will happen infrequently and cannot be prevented.

    The person making the error is generally distraught and stressed over having made the error. And he/she will work hard to make sure it doesn't happen again.

    2. Incorrect procedure

    The second category of prescription error occurs when someone fails to follow the correct procedure. This failure leads directly to the error being made and or not corrected.

    These kinds of errors can be minimized, and a willful failure to follow correct procedures is an offense that should lead to termination. Willful violators of policy fall into two categories:

    • Knuckleheads who should be terminated.
    • Sincere people who are overworked and trying to get more work done than they have time to do it.

    Sincere folks need to be listened to because your company policy is probably in conflict with your staffing budget. Be careful not to kill the messenger, but also understand that knuckleheads will always try to deflect blame onto someone else.

    The key management decision is deciding which type of person you are dealing with.

    3. Lack of procedure

    The third category of prescription error happens when there is no well-designed, efficient and sufficiently-staffed process in place to prevent errors.

    This type of error is a failure of management, and blaming it on employees would be absurd. It is leadership's responsibility to develop efficient processes and train everyone in their use.

Many large employers confuse these three types of errors and end up rewarding the knuckleheads and firing the good people far too often without reflecting on the true root cause of the error.

A bureaucratic system looking at errors has to be careful to understand that errors are made in real time and often without the benefit of the unlimited time, budget and staff to figure out what happened. Far too often people who have never been in the heat of battle question the hearts of those in the direct line of fire and impose ridiculous and illogical mandates on their staff.

I am reminded of an elderly patient who was livid over a minor error that was made on the label of her prescription. She admonished our staff with the following statement, "The next time you are going to make an error on my prescription, please tell me when you hand out my medication." I said, "Yes, ma'am, and went back to work."

Obviously, her request was absurd on many levels. If I knew of the error, I certainly wouldn't dispense it. But I wonder sometimes if organizations aren't misunderstanding what type of error was made and placing the blame on the wrong party.

Error data is notoriously unreliable because the people making the error are afraid it will cost them their job. That is a recipe for a bad quality-control process.