Worst reasons for near misses


I want to share with you some of the excuses I have heard from staff when they make a dispensing near miss. I appreciate that we are all human and, therefore, make mistakes but I can’t help feeling annoyed when instead of a simple apology and moment of recognition the following excuses are blurted out on a daily basis as to why the mistake occurred:

1. It’s too hot

2. It’s too cold

3. I’m hungry

4. I had too much to eat at lunch

5. It wasn’t me (no one owns up and the label is not signed)

6. It wasn’t me (they dispute it even though they have signed the label)

7. I just stuck the labels on, I did not dispense it

8. The box is a different colour and I got confused

9. The box is the same colour; it’s just a different drug unfortunately

10. I labelled it as amoxicillin 500mg so don’t understand why the label came out as amoxicillin 250mg

11. I’m thirsty

12. I need a wee

13. That’s what they had last time

14. I didn’t label it, it’s the labeller’s fault

15. I thought it said glycerin suppositories not glyceryl trinitrate spray. Is there a difference?       

What’s the worst reasons you’ve heard?

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6 thoughts on “Worst reasons for near misses

  1. No 6 is hilarious..ive never had to deal with someone like this!!lol!!Okay, i have to admit No 14 does get on my nerves!!!!!!!*big time*

    When ever someone gives me this excuse…I always reply bck by saying if youve put ur initials there,ie, you taking responsibility that uve dispensed the right medication.

    No15..no comments!!LOL!

    I knew a dispenser whom i wrked with, she always had a valid reason..oh i was feeling too well, the phone rang, smeone was talking to me…All I can say now is that shes not a dispenser anymore..she did step down!!! One pharmacist said to me”Oh God, that woman is a liability”

    I make my dispensers write their own mistakes in the error log..n yes I do check at the end of the day if theyve written it down.

    Its a good blog, it definitely made me laugh!

  2. Excuses always arise when you are not paying attention.its as simple as that. How much dispensed, expiry, label & product (HELP) never fails!! I’ve tried it for 6 months. It’s simple and tried so I’d advise all dispensers to use it unless they’ve got better pnemonic. 
    Mental break–even few seconds of looking away, helps!
    Gradually confidence is built however , keeping oneself from going on autopilot is better because that’s when you dispense without looking and yes, all the box colours and fonts you identify the product with, suddenly CHANGE and disaster strikes !!

  3. A near miss error log is a good idea, especially with the names of the dispensers who have dispensed the error. This could hopefully reduce the rates of errors by them.

  4. Here’s a few more examples from my colleagues…
    1) I went off the PMR
    2) Im not feeling well
    3) Im still training
    4) I didnt have my glasses on
    5) Someone put that on the wrong shelf
    6) I always do that wrong, get used to it!!!

    Nevertheless, i dont complain as it could be worse!!!

  5. To be fair, I have worked in places where Numbers 1 and 2 could actually be a legitimate excuse. Big shopping centre pharmacies tend to have the dispensary heating set somewhere upstairs through the back and can’t be changed by the staff, meaning you tend to sweat all the water out your body running around the tiny, stuffy dispensary trying to do the work of 6 people alone. And I have also worked in places (including my pre-reg site) with no heating. There was a foot of snow at one point during my pre-reg yet we had no heating in store. I had to put my hands in the fridge for a heat just so that I could write, seeing as the fridge was 7 degrees and the dispensary was only 2. Its also common for no-one to actually know how to set the heating/air conditioning in a pharmacy as no-one has ever explained the myriad buttons and pictures of snowflakes on the control panel to them.

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