I opened this morning’s USA Today while on the road, and was struck by this story. It details how a simple clerial error on the part of a pharmacy technician resulted in wrong dosage instructions – “As Needed” rather than “4 pills, 2 times per day” – and a fatal overdose for a Florida man.

The man took 22 pain pills in a 36 hour period.

Clearly there are numerous points of failure in this story, as well as the entire drug dispensing process. The article does go into many of the process factors at play in the incident, as well as the various error-proofing techniques pharmacies are now using to prevent errors from happening.

But what continues to trouble me is the recurring theme that the workers involved didn’t care enough. I have no reason to believe that the pharmacist and pharmacy tech did not give their “best efforts” – but as Deming tells us, something more is needed. (Interestingly, the commentors on the story cite problems throughout the process, not just the pharmacy tech’s mistake.)

So readers, what more is needed? Post your thoughts in the comments section.

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