He said - she said... and the BLACK HOLE of pharmacy

It's a very common problem in pharmacy.  An order is sent down to the clean room for stat antibiotics.  The pharmacist quickly enters the medication order into the pharmacy order system and labels spew out at a printer near the laminar airflow hood.  A pharmacy technician is verbally alerted to the "hurry up" nature of the order and diligently prepares the life saving meds.  They are checked by the pharmacist and set out on the delivery table to be sent up to the nursing staff.

High fives all around!!  Team IV Room just saved a life.

Or so they think.

Thirty minutes later, a call from the nursing unit manager goes something like this.

Nurse: "I sent that order for Mrs. Jones down 30 minutes ago.  It was clearly labeled STAT.  I've been standing by the tubes and checking the med room - no drug.  The family is very upset and the doctor is calling me to see that it has been infused.  Where is it?"
Pharmacist: "We prepared that med in record time and had it on the delivery table in less than 3 minutes.  It should be up there."
Nurse: "It's not here."
Pharmacist: "I sent it."
Nurse: "No, you didn't."
Pharmacist: "Yes, I did."
Nurse: "Do you want to take this outside..."

OK, so I exaggerate a bit at the end, but there is a palpable feeling of animosity in the air.  The pharmacy staff, now feelings of celebration long gone, starts the process of duplicating the dose - an expensive proposition both in terms of time and money.

As a pharmacist, there were times when I was working in the IV Clean Room where I, personally, would hand deliver medications to nurses because the anger and distrust had mounted so high.  Our personal as well as professional reputations were at stake.

Where did the drugs go? THE BLACK HOLE OF PHARMACY.

Patient transfers, meds delivered to old unit; delivery cart bumps on the gap between the elevator and the floor, meds slip into oblivion; delivery of meds by tube, routing number entered wrong and sent to central services... the black hole is endlessly sucking drugs, time and money into it...

Pharmacy Practice News dropped into my inbox yesterday and I read the last article in the journal wistfully.  How I wish we had a solution like MedBoard to track down where the meds had gone.  Read the article.  Money, time and the reputation of our profession are at stake.

charles