Pharmacist on duty the evening that Francis Abbott's prescription was filled. 

(Background)  I have been a pharmacist for three years now, I worked for 2 ½ years as a hospital-based pharmacist and have worked as a community pharmacist at Sunshine Community Pharmacy for almost 6 months. 

On the day of the event, Mrs. Abbott's family doctor faxed in a prescription late in the afternoon that day, for warfarin and metformin, and she also wanted a refill of her metoprolol.  I reviewed the new prescription and approved it.  I also made a mental note to check with Mrs. Abbott regarding the new dose of warfarin to make sure she knew that the dosage had changed.   

I then passed the prescription on to Evelyn to fill it.  Evelyn was answering the phone and she called me over to speak with a physician who had called back regarding a clarification I needed for a prescription.  Once I finished that call, I got another call from a customer requesting a refill of their medications, so I logged that.  Mr. Johansson then came in about twenty minutes to 5 to pick up his prescription. I had told him it wouldn't be ready until 6, but he showed up early, and he wanted to talk to me about a possible interaction with his medication and an OTC medication he was also taking. 

When I finished talking with him, I noticed that Mrs. Abbott was there, so I quickly checked her prescription –– I was behind on checking prescriptions because of the phone calls and needing to talk to customers.  I didn't open the pill vials to check – I used to do that, but it is so rare that there is ever a mistake, that I have kind of stopped doing that - but I did check the stock bottles against the vials. 

I brought Mrs. Abbott her medications and spoke with her to clarify the dose of warfarin. She received the teaching sheets we have when she started on the Warfarin, so I don't give them out every time, but I do speak to the patients when their dose changes. I asked if she had any questions - she said she didn't have any questions, then she left the pharmacy. 

I remember being quite tired around the time of the incident with Mrs. Abbott's medication.  I was coming to work very tired as we had a new baby in the house and she was not sleeping well – so none of us were getting any sleep. 

Our policy and procedure manuals are up on a shelf in the dispensary so anyone can access them if they want. To tell you the truth, it is a pretty big binder and I am not sure of all the policies that are in there.  I am familiar with the important ones – we do have a dispensing policy, but I am not sure exactly what is in it. 

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