Somebody Didn’t Care Enough To Be Right

I found a dreadful news article about a man who died after taking an overdose of the painkiller methadone.  The reason why he took the overdose is because the directions typed out by the technician in the pharmacy said “take as needed” as opposed to the doctor’s prescription “take 4 tablets twice daily”.  Tragically the gentleman in question took 22 pills in a 36 hour period, nearly twice the recommended dose, and his wife found him dead in the shower.

His widow is quoted as saying “Somebody didn’t care enough to be right…”  I agree with her.  The question is who?

Some background information:

• The technician responsible was a part time 22 year old.
• She didn’t know what the side effects of methadone were.
• After the incident she was sent on an error prevention course.
• A qualified pharmacist was responsible for checking her work, and did so that evening without noticing the error.
• The pharmacy was very busy, that day they dispensed 380 prescriptions.
• The error happened at a peak time of the day.
• The pharmacy was short staffed, people worked through their breaks.
• The pharmacist had been known to say that the work load was stressful and getting to her.

So who was responsible?  The technician, the pharmacist, or the manager responsible for capacity, process and cost?

I have a position.  Do you?

Photo by kgrkz on Unsplash