iSixSigma

And Someone Didn’t Care Enough to Be Right

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.

Comments 1

  1. Chad-Vader

    Although I find this story interesting, I must quote Ron White on this one; "You Can’t Fix Stupid". My point being if you are such a moron that you have taken 22 pills in a 36 hour period, and you don’t find that to be odd, as an adult, then maybe the writting on the bottle would not have changed the outcome. Even an Asperin bottle has statements as to how many to take, and not to exceed in a 24 hour period. Not going to change how many Some people will actually take.
    We have become a society of finger pointers and someone is to blame, well maybe the guy taking the pills is to blame. I would be more upset about the wrong pills getting put in the bottle than the actual writting. Someone can correct me if I’m wrong, but with all pain killer medication, pharmicist not only go over the dosing, but also give out propaganda as to the potential addiction to pain medications and that should only be taken in AS NEEDED dosages.

    But I’m sure there is a Lean Six Sigma Project just "Dieing" to be sprung.

    Just My Opinion

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