Pharmacy U presenter Kristen Watt: Destigmatizing errors in pharmacy practice

Kristen Watt, BSc Phm RPh will be the Opening Keynote speaker at Pharmacy U Vancouver: Double double, drugs and trouble: confronting the fear of medication error

"Medical errors are ubiquitous and almost never dangerous if we admit it and deal with it."

This was the response from the physician after I reported a gutting medical error. In November of 2022, I was offering a vaccine clinic on a short Saturday shift. As had been the case since June of that year, I was the only pharmacist on duty. I had a technician to help with dispensing and had only 30 appointments for vaccines that day, a tiny clinic compared to other days, including a 1,000-dose drive-up clinic we had held.

We often hear about the Swiss cheese model of medical error. On this Saturday, the Swiss cheese aligned and I gave a toddler the wrong vaccine. And the toddler’s older sibling. Worst yet, this wasn’t my first mistake that fall.

Another patient in our pharmacy had received a blood thinner when none was ordered. This patient then had a clot, then a bleed. The cascade of events was unfathomable and yet all happening to my patient following my error.

I could see the headlines now: “Former Pharmacist of the Year loses licence over medical errors.” I could see my name in glossy print in "Pharmacy Connection" in the discipline section.

I finished the vaccine clinic in tears. But I also acted. Contacting the parents. Using clinical judgement to assess harm. Contacting peers for reassurance and contacting the patient’s physician. I removed any plan of another poorly staffed vaccine clinic from the future. I did root cause analysis on both cases. I accepted responsibility. And eventually I forgave myself for my part in the errors.

When I told peers about my mistake, I was made aware of their mistakes. I hadn’t heard these stories before. We don’t talk about this in our Facebook groups or WhatsApp chats. And I realized: we are making a big mistake by not talking about mistakes.

I am using this opportunity to tell you about my mistakes. To destigmatize mistakes. To hear from experts about professional practice, remediation, and discipline. To talk about root cause analysis and the true utility of being honest with yourself. To legitimize initial feeling of horror, despair and gut reactions. Medical errors are ubiquitous, and how we deal with them is the most important piece.

Kristen Watt, BSc Phm RPh will be the keynote speaker at Pharmacy U Vancouver: Double double, drugs and trouble: confronting the fear of medication error