Lesson 1: You WILL be thrown under the bus

I had a great boss who always told me and others he would stand behind us in any time of turmoil and would gladly take a bullet for us to protect us in the event something happened that was the result of a failure of process. I had no reason to not believe him. Compared to other directors, he was far more transparent and true to his word.  Unfortunately when push came to shove, even my progressive boss threw me under the bus.  

On a random day several months ago, about half way through my work day, my boss pulled me in and told me some odd things and quantities were missing and it had my name all over the reports as the person who last touched them. Third shift discovered the issue and gave to my boss to follow up. My boss gave me the reports. I suggested others to run. We could not find an error in procedure on paper.

I told my boss that at least one of the items I remembered taking out to be prepackaged on our unit dose machine and had set it where we always put things to be packaged by the machine. I also told him I had never removed one of the drugs and that another one of the drugs I didn’t even know existed let alone that we had it in stock. I pointed out the lack of an auto logout on the machine and the fact that reports clearly showed that I checked out a stock bottle of drug followed checking out the two weird drugs over 6 minutes later without first logging out and back in again. I proposed that perhaps someone else came up behind me and performed the action on the two odd drugs and that the ones removed for prepacking were probably just misplaced somewhere.

Keep in mind that at that point in time my little Ohio hospital had a pharmacy department with NO CAMERAS in it. All we had to go on were reports and my recollection of the events.

We looked everywhere. We found no stray drugs. As for the drug that needed prepacked it wasn’t where I had always put drugs needing prepacked and there were no records of repackaging in the software.

After significant searching and discussing for about an hour, I was told to gather my things and was whisked to HR where I was questioned, drug tested, given a breathalizer and put on administrative suspension. I called my boss from the parking lot rather distraught, and asked what the hell was going on. Policy and procedure I was told. They had a protocol for this sort of thing and I just had to sit it out. I asked if I should worry and he didn’t think I needed to worry. It was odd that those drugs were missing but we both agreed there had to be a logical explanation. He even ran more reports and actually emailed them to me to look at to see if I could figure something out since I was the guru on such things.

After a few more hours of searching to no avail, my director then and only then decided to contact the state board of pharmacy.

Anyone from Ohio who is a pharmacist will clearly see the epic fail in that story. Before HR got involved, before I was questioned, and most importantly before I was even informed of the problem, it is the Adminstrative Code that the state board be called to help determine what thenext action should be.

O.A.C. 4729-9-15 states:

(A) Each prescriber, terminal distributor of dangerous drugs, or wholesale distributor of dangerous drugs shall notify the following upon discovery of the theft or significant loss of any dangerous drug or controlled substance, including drugs in transit that were either shipped from or to the prescriber, terminal distributor of dangerous drugs, or wholesale distributor of dangerous drugs:

(1) The state board of pharmacy, by telephone immediately upon discovery of the theft or significant loss;

So the hospital and my director, by their own admission of guilt later in the process, violated the law of the great State of Ohio. They did so because they were following to the letter the hospital’s policy and procedure about what to do if a drug goes missing without explanation after a reasonable amount of searching or fact finding.

I on the other hand, had done nothing wrong in terms of the law. I had been stupid and careless and too trusting by not logging out and by putting the stock bottles in a bin by the machine with the assumption they would find their way back into the vault. Despite my stupidity, I had not violated any laws.

Due to my stupidity and lack of realization of the implications of the law violation by my director, I initially understood the suspension and the drug testing. Policy is policy. I’m not the boss. These were corporate policies. They had to be lawful and correct in my mind. I fully expected to be reinstated a few days later with a simple write-up for carelessness.

What happened after that first day is why this blog exists. That violation of the OAC by my little Ohio hospital and my director snowballed into a massive debacle and thusly turned careless work processes on my part into career limiting moves.

The moral of this first and most simple part of this story is as follows:

If a controlled substance goes missing from a hospital pharmacy and the reports show that you touched it last, never trust that your boss or facility has other failsafe mechanisms or lawful policies in place to protect you (or that your boss will assist you in your plight).

You WILL be thrown under the bus.

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