The culture of safety and transparency: Can you have one without the other?

A couple of weeks ago, I was charged with picking up a prescription for my mother-in-law at a chain pharmacy. I dutifully picked up the ‘script and headed home. When we opened the bag, my wife and I observed that while there was some paperwork attached to the bag, the pill container inside the bag was not labeled. My wife (who is a nurse) tried a couple of phone apps to determine if the pills were what were expected but couldn't really come up with anything conclusive (my mother-in-law had recently been discharged from the hospital after fighting off a couple of infections).

So, I went back to the drive-through and informed the person at the window (I’m presuming a pharmacy technician, but no one really introduces themselves anymore, do they?); the tech looked at the bag and its contents and informed me that the label was there on the paperwork attached to the bag. To which I responded, “How am I supposed to know that?” The whole purpose of the labeling process is for the pharmacist to verify that the contents of the pill bottle are consistent with what was ordered, the patient is correct, etc. The tech indicated that the unlabeled container was an error on their part, though still insisted that the information on the bag was enough to figure out that the order was correct.

At no point in the conversation was there any tone or words of apology, regret, etc., minimally for the error, but also for my having to come back on a Saturday afternoon. To my mind (and to my practice), if there’s an error, you own up to it and you make it right. In this case, I know the tech just walked out of eyesight and put the label on the bottle; perhaps the pharmacist was consulted, perhaps not, but one would think a “sorry about that” or some such acknowledgement would have been appropriate. And I’m pretty certain that, even in admitting that they had made an error, I don’t think that the accountability for the error really registered.

We have talked about this before (just about two years ago) and it really boils down to keeping errors away from the end user(s). I know humans are not perfect, but there are certain processes (like filling prescriptions) that are more sacrosanct than others and deserve as much diligence in ensuring accuracy as possible.

I suppose this is amounting to one more “old guy” yelling at kids to get off his lawn, but if my wife and I weren’t checking, how do we know that everything was in order with the prescription. I know that not everyone has someone to look out for them, and this just seems a little more cavalier than I would prefer. It is somewhat analogous to the feelings I have when I thank someone and they respond, “no problem.” Definitely an old guy thing—I am an enormous fan of “you’re welcome,” but why do I have such a problem with “no problem”—perhaps therapy would help.  At any rate, there does seem to be an increasing reluctance to take accountability for errors, which seems to fly in the face of the culture of safety movement (hopefully it’s still a movement). I can appreciate that there’s an expectation to do more with less and that accuracy can sometimes be forfeited, but I can’t imagine that that is a good thing. Do you?

About the Author: Steve MacArthur is a safety consultant with The Chartis Group. He brings more than 30 years of healthcare management and consulting experience to his work with hospitals, physician offices, and ambulatory care facilities across the country. He is the author of HCPro's Hospital Safety Director's Handbook and is an advisory board member for Accreditation and Quality Compliance Center. Contact Steve at stevemacsafetyspace@gmail.com.