Wednesday, January 17, 2007

oops. medication mismanagement.

The other day I realised I had made a grave error in my evaluation of a graduate’s practice. Actually my mistake was even more elementary than that – I evaluated their practice but did little to follow up on my assessment.

Six months later it has come back to bight me!

Six months ago I observed a graduate make a medication error. I pulled them up, they rectified the problem, we discussed the importance of careful checking during medication administration and the graduate stated that they would slow down when giving out the pills. All was well.

Time passed, and somehow I never got back to observing the graduate’s medication practices again. Perhaps I saw them dispensing Panadol or Nexium as I passed through; maybe I stood beside them as they checked a patient’s armband; but I didn’t consistently stand and assess their medication management from start to finish. They were so self-assured and confident of their practice, advising me that of course they were careful. Their preceptor advised me that they had not noticed any problems with the pills. So I laid my concerns aside and moved on to other issues. Problem solved.

How wrong I was!

It’s January and graduates have a few short weeks left in which to complete their professional portfolios. They are running around in a final flurry of activity, scrambling to write episodes of practice and achieve all their learning objectives. Every year it is the same, and I am inundated with calls for assistance – ‘please can you sign me off on this. And this. And this. And, oh, there’s also this one!’ In my kind heartedness I spend as much time with them as I can and try and maintain impartiality in my assessments.

The graduate of this post had not been signed off on - you guessed it - medication management, so I agreed to observe her in practice and make my assessment.

That was when it happened.


Another wrongly dispensed medication. Another near miss that I had to point out. Another hasty correction. Another discussion about the importance of careful checking.


Here they are at the end of their graduate year, and still making the same mistakes as they were at the beginning of their placement. And how many more unidentified mistakes have they made in between?!

Of course the graduate must take responsibility for their lax practices and errors, but shame on you muse, shame. You could have done something about this and didn’t. You too must take some responsibility for this situation.


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