Thursday, May 7, 2015

Another meds failure

---Note to readers---
One reason I protect my anonymity is so that I can write about personal matters that I know other people might share.  These are issues that are seldom discussed due to privacy concerns.  The inability to share problems and solutions results in each of us making the same preventable errors.

I try to leave out the details that are not germane to the topic but need to include enough information to sketch out the scope of the issue.  I attempt to describe circumstances in a matter-of-fact way.  Perhaps I can help one or two readers avoid some of the landmines I found.  That is my hope.
---End of note---

We had another meds dispense failure this weekend.

I botched the morning drop.

We pre-load a weekly caddy with the various doses.  The patient normally has fourteen separate pills administered over the course of the day.  In addition to those, the patient is currently being treated for an ear infection which added three pills in the morning (an antibiotic, an antihistamine and a decongestant).

The root cause of the dispense failure was moisture in the bottom of the pill bottle I used to carry the pills from the caddy to the patient.

I like using pill bottles.  The caps are very secure.  The material is robust and abuse resistant.  They are of a size that both fits in a pocket and yet can be readily found and pulled out.  The pills are easy to put in them.  And they are easy for the patient to toss them down-the-hatch.

Easy for the patient to toss them down-the-hatch except when there is moisture in the bottom of the vial.  The gelatin coating on the individual pills almost instantly turns to a gelatinous slime that glues the pills to the bottom of the vial.

Somehow the pill bottle I selected had residual moisture in it.

I did not check the vial after the patient handed it back.  The vials are either amber or dark green and the room is dim.

The patient must have suspected something because they checked the vial about mid morning and noticed about six pills were stuck in the bottom.  Unfortunately, several of the prescriptions are extremely tiny, white, anonymous looking pills and we were not able to determine exactly which meds had been missed.

One of the factors that influenced our response is that we did not know with certainty that the vial with the stuck pills was actually from that morning.

We gave the patient the one prescriptions we were able to identify with 100% accuracy that was stuck in the bottom of the vial and that had the least downside with respect to an overdose.  Then we dropped down into "limp home" mode.  That is where all of the environmental factors that exacerbate the condition are pegged in the most favorable condition.  We made it to the evening med drop without incident.


I will write the day-of-the-week on these caps to address the issue of not knowing which day was missed in the event that we do not catch the problem immediately after the med drop.

This is the second time we have had the "moisture sticking pills in the bottom" problem.  Obviously, something needs to change.

I opted to buy some dedicated pill dispense bottles.  They are clear which will help with visual inspection.  They are shallow. And they appear to be wide enough so even the longest of pills will not lodge in them but small enough to be easily pocketed or put in a purse.  They have screw tops.  They cost $20 for 28 of them on eBay.

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