Accidents happen: Part Two

Did I say “accidents happen” the other day??

What was I thinking?!

It’s like saying its q___t at work; never say the Q word!! It invites chaos and busyness and problem scripts one after another. But I said accidents happen, and so they did! Fate heard me, even though I don’t really believe in fate…oops, is that another invitation to the world to punish me?? Well punish is a bit dramatic, but you know what I mean.

So I’ve been recovering from accidents and errors ever since I wrote about accidents!! It wasn’t enough that I had my first ever minor car accident last Friday. On Wednesday, I had to go and fall down the stairs!! Like a really idiot!

I think it was sleep stupor, but to be honest I don’t really know. It was morning so sleep stupor could cover it; not much of a morning person, me. I took one step down leading with my right foot, another step down now with my left foot, another with my right and then I just slipped off the far edge of the next step with my left foot and I was gone. Our stairs go halfway straight down, turn 180 degrees then the other halfway straight down. Pretty standard. I slipped on almost the last stair before the turn. It might have to do with the stairs being shaped as wedges for the turn and I hit the tiny point of the wedge. I don’t really know how but somehow my left heel hit close to the edge of the stair and just slipped right out from under me and slipped over stair after stair after stair with no grip on any of them. My left leg was a useless slippery pointy thing sticking out in front of me causing nothing but trouble!!!

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Brain kicking into overdrive trying to figure out what to do, hoping to hit the wall at the bottom of the first half of the steps, grabbing the railing by instinct rather than thought, left leg useless sticking straight out front and can’t get a foot hold anywhere, getting half a grip on one stair after another but slipping over each and every one, poor right leg tucked underneath getting banged and scraped stair after stair after stair!!

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Luckily, and there is always an aspect of luck with me somehow, I was trailing my hand down the banister and managed to grab it! And even though my grasp slipped down the banister, it got caught on the post halfway down at the corner and I managed somehow to haul myself to a stop. I’ve seriously wrenched my neck and back and arm because of stopping myself but at least I didn’t go head over heels or something worse. And at least my hand was in contact with the banister when I fell; usually I don’t hold on at all! So it could have been much worse. Apparently its a workplace OH&S recommendation to have 3 points of contact with stairs at all times: 2 feet and 1 hand, or 1 foot and 2 hands if you are that person who just has to push the envelope! So maybe I need to put up some OH&S posters in my stairwell!

Panic as several steps went by and I missed the wall at the end, turning instead to start going down the next flight! Finally gripping the railing at the post as I slid to it and holding on for grim death!! Or is it life? Either way, I managed to stop on that poor banged up left hip with my useless left leg still sticking out in front, and the even more useless right leg underneath and my arm twisted backwards at some weird angle. So by the time my hand found a hold on the midway post, I was through the corner and heading down the next straight with my right leg tucked well under me getting cheese grated on each and every step where the carpet is bare and the strings are coming through. Basically I got a combination of carpet burn and grating right down my shin and a good few bumps on my left hip, which is swelling up nicely. I was feeling pretty shabby!!

So I was pretty stoked to have come to a stop, even if it was at the cost of the whole left side of my torso and arm. But how to get up?? I’m not a little thing, as most of you probably know. And unable to engage to use of either leg and one arm and side made getting up some kind of origami exercise! I actually can’t tell you how I got up, but there were a couple of bad moments where I started to slide again. But here I am to tell the tale!

So I grabbed on for dear life and managed to stop my fall. There was a moment of real horror thinking that the post might let go; I definitely felt it give. But when I went back afterwards it was as solid as ever. But as it turns out 120kg dangling by one arm is not only a threat to the wooden stair railing but to the muscles and soft tissue behind my shoulder blade. OUCH! Before too long I couldn’t turn my head to the left more than 20 degrees, behind my shoulder blade was singing and I was rapidly becoming frozen stiff. So a trip to the physio to get ironed out.

To look at you can’t even tell I’ve had an accident. Well not until I covered the grazes along my shin with white dressings that is, they kind of stand out on my tan! Not intentional but there you go. It saves me feeling like an attention seeker telling people about my accident; the bandages seek your attention on my behalf!! Is that the same thing?

Its amazing the pain and irritation such superficial scrapes create. Bed sheets, leggings, any clothing just rubs so I headed down to the pharmacy for some dressings so I can at least be a bit more comfortable. Now at least the stinging doesn’t keep getting set off again. But stretching the skin by moving it any way including walking is still aggravating. So here we are, another accident. What to make of this one? I really don’t know what went wrong so that I can avoid it again. Just one of those things? Or I should take more care?

So that was my fall. I thought that was enough, how about you?

But no. I get to work and start my usual Thursday; you know, all the packs and stuff that I wrote about recently. Then my boss brings one of the packs to me and says it has been brought back to the pharmacy over an error! That shoots straight through the heart. Especially right on the heels of having experienced a dispensing error and making (possibly) a big deal about it. As it turns out I hadn’t seen that there were 2 loratadine (you know, Claratyne the anti-histamine) tablets instead of one in Tuesday morning. It’s a robot error, but my job is to pick up that type of error, and I didn’t.

I could justify my omission by saying that its not that serious an error; in all likeliness there would be no side effects as loratadine generally has no more side effects than placebo (sugar pill). But the point is that I missed the error.

I could justify it by saying that the patient hadn’t taken it yet so it wasn’t so bad.

I could also justify the error with the conversations I’ve regularly had with other pharmacists checking packs discussing how extra tablets in packs is the hardest error to pick up, compared to other errors: broken tablets, missing tablets, wrong tablets. But I still missed the error. Not good. But it has made me further reconsider my response to the dispensing error that happened to me.

But wait, there’s more!! Unfortunately.

This, I suppose, is what happens when you only work twice a week. Short of them texting you about issues on your days off (it happens!) they save them up for next time you come in!

So, it seems that I dispensed a patient’s 500mg Epilim (valproate) correctly, then attached the labels to 200mg tablets. THIS is a problem. This is a big problem. I don’t know why the patient was taking Epilim but irrespective, taking this error over weeks to months WOULD have resulted in a relapse had the patient taken it: a relapse of epilepsy resulting in seizures, a relapse of bipolar resulting in depression, mania or suicide or worse. As someone who takes Epilim and dreads the probably inevitable day that I relapse, I can totally empathise with the patient in this scenario, as well as my position as pharmacist!!

I could justify this error by…nope, nothing!! I should have scanned the medication against the dispensing; this would have shown the error. I should have compared the original script to the box of tablets to reconcile the strength; this would have shown the error. I could have reviewed the history, but that’s an extra step. All I needed to do was the 2 steps mentioned; that would’ve prevented the error. Luckily the patient identified the error, brought the medication back and no harm, no foul.

Sound familiar?? My high horse is sinking through quicksand and I’m about to go down with it, unless I jump off and acknowledge that I just made an error as significant as that other pharmacist, and how do I want to be treated over this? What lessons do I need to learn? How would I feel about being reported to the pharmacy board? My boss knows, so that aspect can’t get worse, but he was very good about it actually.

Can I console myself with the errors that I did pick up today? 5 missing doses of magnesium in one pack, 2 missing dose of metformin (for diabetes) in another, a broken Panadol tablet making an underdose, a broken clonazepam tablet (for seizures or spasms) underdose, double the Efexor (antidepressant) dose in one slot, a random thyroxine (for underactive thyroid) tablet found in a pack where the patient doesn’t take that medication, and more. Does it make up for letting a more severe error pass through to the keeper? In short, no.

But it does make you think. Here I am, on a squared playing field, accepting that human error exists but there are systems to obey to minimise it, and ignoring the systems is just not on!

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Canberra Day 94

[Wednesday 14th December]

Well today was a terrible day career-wise, nothing fatal but nothing fun, so it’s a good thing that I’m in Canberra with a licence to explore and enjoy new experiences.

I’m having some issues with the Australian Health Practitioner Regulation Agency (AHPRA) that manages the registration of 14 different health professionals, including pharmacists. Previously we had our own pharmacy board, but in 2010 several boards were amalgamated and now we are managed jointly. This new organisation, AHPRA, manages our annual registration including our compulsory continuing professional development (CPD) requirements, whilst another organisation manages the regulation of pharmacies and pharmacy departments. All very boring and tedious, until your annual registration comes up against a problem. In my case a CPD problem. Each year between October 1st and September 30th, every registered pharmacist in Australia now has to achieve 40 hours of CPD to qualify to be re-registered. After the amalgamation the amount of CPD to be achieved began as 20 hours and increased over a couple of years. Its pretty standard now, and pretty achievable if you’re working, which is the point; to keep you up to date.

I first went on sick leave in March 2014 and stayed on sick leave for several months before I dragged my reluctant body back to work only part time for 6 weeks in September/October that year to complete my contract at the Alfred, in the vain hope that I would build up professional fitness quick enough to convince my workplace that I was fit and well to work and be re-hired. I was desperately hoping to stay on because I loved that job. It was a joke looking at it now; there was no way I was even fit for the very part time work I was doing then let alone more. But the point being, between October 1st 2013 and September 30th 2014, the annual CPD year, I worked 6 months and work generates CPD as does starting a new job as does changing positions within a job all of which applied to me. So even at the 6 month mark when I got sick I had oodles of CPD numbering probably around 50 or 60 hours. So I finished my feeble 6 weeks in dispensary, ended my contract and went back to bed.

By the time I got going again and went back to work, it was July of 2015. Already up to 9 out of 12 months of the CPD year, and to be honest, to this point CPD hadn’t even crossed my mind! A little teensy nervous breakdown and the associated issues had occupied the major part of my brain for months on end and work had just gone away. Even now returning to work I was conscious of the need to get up to date with the many new drugs and devices that had hit the market in the last year and a bit, but I hadn’t thought particularly of my CPD requirements with respect to my registration. I did all the required new job CPD, I did study on things that were relevant, I recorded it all and never really thought of whether I was making the 40 hour amount. Which is unfortunate, because I didn’t make it! I got 25 hours, not 40.

And there is no clause for people on sick leave. Or for people not working. You’re either practising or not practising. So, in November 2015 when I was re-registering as a pharmacist and got to the compulsory question about whether I had completed 40 hours in the previous year, I had to answer in the negative as in I did NOT meet the CPD requirements. And I won’t say that all hell broke loose, but all kinds of official pharmacy correspondence started flying around the web and through the postal service, and today is just another step in the painful process that is rectifying the situation! I’m not complaining about having to fix this up; I should have to. I’m a health professional and patients need to be sure of me being up to date and on top of the latest drugs and professional practice. I’m just complaining about the amazing bureaucracy that prevails in these matters! It is not easy to show that you have done your best to fix it, that you’ve learnt your lesson, and that you’ll do better in the future. Especially if you’re out of work again, because things just don’t come up when you’re not dispensing and reviewing medications on a daily basis. You have to actively look for things, and it’s just harder. But it’s part of my commitment and I have to just get on with it. So I’m off to send yet another email, which will probably get yet another “out of office” reply, followed by an actual reply sometime in the next two weeks or so telling me that there’s yet another technicality that I haven’t met because I was never told about it, followed by another email from me phrased very conservatively despite my inner rage and so on. You get the drill!

So there’s that, and following that the awful words “we’re terminating you”!! Seriously?! I went back to work officially in June 2015 with a fixed term 9 month contract. I guess I always assumed that there would be a possibility for extension at the end, assuming they liked me and my work was up to scratch etc. But no, despite putting me through two traditional interviews and a non traditional observation of practice interview I was never successful in getting an extension. So I was told I would be put on the casual list and they’d call me, which they never have but that suited me lately being in Canberra and all. So now out of the blue I get a call to say sorry, it’s just a HR thing but because you haven’t worked for us in 3 months we have to terminate you!! I’m sorry, what?! I’m costing you zip, I’m (usually) a resource available at short notice a 4 minute walk away, and if this was always a HR thing, why didn’t you just say goodbye at the end of my contract, instead of giving me an impression that I’d be called up to work?? So when I get back I have to return my keys and it’s all over. Well what a wake up!! Could this day get worse for my career?

Luckily I have good things planned so let’s off to the High Court to observe other people getting the rough end of the stick, potentially. I won’t pretend to understand the case that was being argued but the solemnity and the ceremony of it all was very impressive and the two counsels arguing were humorous in their own way, especially one who referred to “my learned friend” at the beginning or end of every sentence! I’m pretty sure even the 5 judges were smiling under their wigs. A bit of light relief, and I’m glad that becoming a lawyer was never on my list. I took my fill then left, remembering to pause and bow to the judges on my way out!

And now to really flush all that career mess out of my system!! I’ve been looking forward to this christmas concert by Igitur Nos at the National Library for a couple of weeks now. Turns out it wasn’t quite what I was expecting…more classical music, Latin and high brow Christmas songs than your typical carols. But it was pretty nice. Then a drive by a few places of interest: the historical and very pink Calthorpes House, and a few embassies.

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Lucky I have a lovely catch up with a friend after lunch. Nothing so soothing as hanging out with a friendly face and chatting away the afternoon. A super cute little baby helps just a little bit too! Happy day…in the end.