Saturday, 18 July 2020

“YOU SHOULDN’T BECOME COMPLACENT WITH YOUR MEDICATION” | WHEN THE PHARMACY MAKE A MISTAKE




“When you make a mistake, there are only three things you should ever do about it: admit it, learn from it, and don’t repeat it.”

Paul Bear Bryant

I’ve had a rough few days and unfortunately, to explain why, I need to tell you a bit of a long-winded story…


So, last weekend, I began feeling physically poorly and called 111 (the NHS non-emergency helpline in the UK) to then be asked by a Doctor what medication I take. I went to my dosette box and realized that my Aripiprazole (an antipsychotic medication) was missing and it was really frustrating to find out on a Saturday night because obviously my GP and Pharmacy were both closed so I had to wait until Sunday morning to ring the Pharmacy. When I spoke to the Pharmacist, I really wasn’t expecting for him to say, ‘we haven’t given you it since May!’ Whilst I wasn’t expecting it as a response, it did make sense because I’d been planning to request a medication increase as I’d started struggling again. So, on the one hand, I was reassured that we were able to pinpoint a cause for my deterioration, but it was also frustrating because it was out of my control.




Once the Pharmacist decided that he had no idea why the medication had been stopped, I decided to call my GP the following day (Monday). The GP looked back through my records all the way to April and couldn’t find a single document instructing them – or anyone else – to stop my Aripiprazole. They told me that it was still listed on my repeat dispensing prescriptions and that the only reason I hadn’t been given it was that the Pharmacy had stopped ordering it with the rest of my dosette box medications. So, I went back to the Pharmacy! Literally, this time!


I met with a Pharmacist and the member of staff who usually puts my dosette boxes together and they explained that on my paper record listing my medications, someone had put a red line through the Aripiprazole and everyone else had assumed this meant that I was no longer on it! The first thing the Pharmacist said was ‘I’m really not happy with what’s happened here!’ and I was so relieved to hear that right from the off-set they were holding their hands up and accepting responsibility for their mistake. Relieved because this is something that – I’ve found – doesn’t happen very often with services in healthcare.


After discovering the red line, the Pharmacist was unable to find an actual ‘paper trail’ as to why it had been penned and who had done it. He explained that their usual procedures dictate that something like that is signed, dated, and the evidence as to why it had been done, supplied. Since staff had failed to do this, the Pharmacist said there’d be a staff meeting and investigation into the entire situation. Obviously, that was quite a decent response and I probably would’ve accepted it if he hadn’t gone on to make a comment that inferred I take some responsibility for it!


He told me that he thought I had become ‘complacent’ with my medication and that he believed I have the capacity to double-check my medication when I’m given it. And you know, whenever my Mum has been with me to collect my dosette box, she’s advised me to check it through and I’ve always said that I was worried it’d look rude and as though I were second-guessing a professional about their job. Yet here was the actual Pharmacist telling me to do that! And criticizing me for not doing it!


And then I had a really rough night… I’d probably actually say it was the weirdest experience of my life… It took a lot of courage for me to be able to tell someone what’d happened because I was so afraid that people would think I was seriously poorly and that I’d be sectioned to hospital for the rest of my life! I also knew how… unbelievable it all sounded and worried that no one would be able to imagine this actually happening and being real. If someone came to me – before this experience – and told me this, I’d probably be sceptical too! I told the hospital staff that they’d think it was strange and they told me that they’d ‘heard it all before’ and then I told them and they literally said ‘well, I haven’t heard that one!’ I’m also fully aware that I’m quite possibly telling thousands of people something that I’ve struggled to tell just a few people in real life, but somehow this is easier. It’s easier to write it down in my little bungalow from the comfort of my own bed and to not see the reaction of the people reading this…


So, you know when you hear an echo of a voice? And it’s like, you know that it stems from an actual voice, yet it isn’t the real voice you’re hearing – it’s an echo of it… I was hearing something like that and it was telling me that my dead cat (who you can read about her here) was in my torn tendon (which you can read about here)! Like I said, I know how completely strange and unrealistic and irrational that sounds, but in that moment… I mean, it’s like a lot of people say when they’ve lost someone – I’d do anything to see my cat again and that desperation became the motivation for me to cut my arm.


Once I’d had stitches in hospital, I was sent to see the Psychiatric Liaison Team (PLT) and after explaining the medication situation, they confirmed my thought – being without my antipsychotic medication had allowed room in my head for psychotic thoughts and beliefs. On the one hand, I was relieved that we could pinpoint a cause for the strange and scary experience and self-harm and that it wasn’t that I had relapsed. On the other hand, I was also absolutely furious and frustrated at the thought that I was paying the price for a mistake someone else had made! I’m usually a very big advocate of taking responsibility for your actions and I accept that I have some responsibility in the situation for reacting the way that I did to the psychotic belief. I mean, some would argue that I shouldn’t even take that responsibility because I was genuinely unwell but… anyway! My point was that the root of it all stemmed back to the Pharmacy’s error with my medication and in a way, it was harder to accept than if I’d been able to blame myself and know that I almost deserved the consequences because I’d brought them on myself.


Fortunately, Aripiprazole isn’t like some other psychiatric drugs in that it tends to ‘work’ a lot quicker, rather than the usual ‘up-to-six-weeks’ warning you get for anti-depressants! This has meant that after just a week of being back on the medication, my head is already growing quieter and I’m feeling happier and more stable. I think that everyone involved in the mistake, have been incredibly lucky that this situation hasn’t had the possible devastating outcome it had the very real danger of having! I think that one key reason why this outcome didn’t occur, was that it was an antipsychotic that had stopped, which meant that me – when I was myself – was still well and didn’t want to be self-harming or attempting suicide.


I think that I’m a ‘look-on-the-bright-side’ type of person and so I try to find the good in situations like this; situations that could have gone very, very badly. In this mistake, I think the positive I can take from it is the realisation that whilst I still need psychiatric medication to remain safe, I’m a lot stronger than I used to be by myself. I’ve also learnt a lot about responsibility and that even though I had to pay the price, it felt a lot better to not be to blame for the root cause of the situation.