Fertility: A Novel (6 page)

“Of course.” Sarah got up and excused herself. She wondered if Doris would engage the pharmacist in her usual chitchat while she retrieved the vial from the safe in John Mess’s office. When she returned, she found Doris reviewing her transcription and Cappelli looking at his hands.

Sarah sat down and showed the pharmacist the vial in the plastic bag. He looked at the label with his handwriting. Then she turned the bag over to reveal the blue label with the clearly printed notation: Heparin, 10,000 USP units/mL. Cappelli took out a handkerchief from his back pocket, blew his nose and wiped his eyes. In no more than a whisper he said, “I’m sorry. I have no idea how this could have happened.”

CHAPTER EIGHT

It was a few minutes after two when Sarah and Albert Cappelli arrived at the pharmacy. In a matter of minutes it became clear what had happened to result in the Arkin baby getting a thousand times the heparin Dr. Smith had prescribed.

The supply of heparin 10 was, just as Cappelli had said, stored in the front of the third shelf of unit eighteen, and the heparin 10,000 supply was stored on the top shelf of unit nineteen. Each location was clearly marked with a label and a bar code. However, behind the heparin 10 shelf label and next to a nearly empty box of 10-unit vials sat a new box of blue-labeled vials containing 10,000 units of heparin. Alejandro, the new pharmacy tech, had restocked the shelves yesterday. Sarah would have to interview him, but it seemed likely he had mistakenly put the look-alike 10,000-unit vials on the shelf where the 10-unit vials were supposed to go.

Cappelli took a long, hard look at the incorrectly placed box and excused himself to use the restroom.

As Sarah stood alone next to the shelf with the offending heparin, she surprised herself with the degree of sympathy she had for the people whose slip-ups had led to the catastrophic overdose. The veteran pharmacist had failed to catch the pharmacy tech’s error when filling the rush order. He seemed to put less stock in the new BCMA system than in his decades of experience in the pharmacy. A nursing pro stretched thin, working with a sick, crying infant and her distraught parents, had failed to notice the discrepancy between the printed and handwritten heparin labels. Surely fatigue would have to be considered a factor in her error.

Just as Sarah was thinking how human — and even predictable — these kinds of mistakes were, the bathroom door opened. Cappelli emerged wearing a look of defeat just as Joanne Marsh approached, seeming to take two steps at a time.

“Joanne. It was me. I messed up. Look,” he said, pointing to the incorrectly placed box of heparin. “I grabbed the vial from the new box just like this,” he said as he picked out a vial from the 10,000-unit box, “saw the blue label and never double-checked the dose.”

Marsh’s face and neck turned pink. She shifted her weight from one leg to the other and folded her arms in front of her. “But Albert, the BCMA wouldn’t allow you to fill the order with the wrong dose. You couldn’t have scanned it. It wouldn’t have scanned. That’s the whole point of the system.” She was almost pleading with him to tell her the system had worked.

“Joanne, you’re right. It wouldn’t scan. I just thought it was a glitch in the system. How long have the 10-unit vials been on the third shelf of unit eighteen? You and I both know that they’ve been in the same place for years. I just grabbed it. When it wouldn’t scan I thought it was some kind of kink in the new system. And the label was blue. They’re
both
blue, they’re
both
blue,” he said, raising his hands in the air. “That’s why we always store the two doses on different shelving units.”

“Who did the stocking of the shelves yesterday?” the head pharmacist asked.

“The new fella, Alejandro,” Cappelli replied. As soon as Cappelli said the name, he knew Marsh would make quick work of him. “But he’s a good kid, Joanne,” Cappelli quickly added. “He ran the scripts up to the floor because I knew the doc wanted them stat. He did everything I asked of him yesterday — and he was nice about it, too. You know, no attitude like some of the young guys. He volunteered to restock the shelves without even being asked. He’s a hard worker. He’s gonna feel terrible when he finds out. He’s not devil-may-care about things, Joanne. He takes the job seriously.”

Sarah could see Marsh’s impatience rising. “You’re being far too understanding, Albert. All the techs have had training in using the BCMA. He was instructed to scan every medication before placing it on the shelf. Had he done what he was trained to do, there would have been no way for him to mistake the 10,000-unit vials for the 10-unit vials.”

“You’re right, but it’s not as though a computer system can’t have glitches. Name one system that doesn’t fail from time to time. We just started it up last week and we’re still working out the kinks. When it wouldn’t scan for me, that’s what I assumed — it was a kink. And maybe Alejandro figured the same as me,” Cappelli responded, defending both himself and the young technician.

Marsh had reached her limit. “Albert, the point of the system — when used as designed and as the staff was trained to do — is to prevent careless errors. If the tech had used the system — and if you had, for that matter — we wouldn’t have a critically ill baby in the peds wing right now. This was human error — the tech’s error, your error and for that matter, the error of the nurse who administered the heparin. None of you used the system as it was designed. And if you had, the error would have been avoided.”

Cappelli was in no shape to argue. He accepted his culpability and surrendered. “You’re right, Joanne. We messed up.
I
messed up. I’m so very sorry.” He turned to leave, shaking his head. Then, as though he’d forgotten something, he turned back and took Sarah’s hand in both of his.

“Good-bye, Ms. Abadhi,” he said before bowing his head to his supervisor and heading for the exit.

CHAPTER NINE

Alejandro Avila was scheduled to work that day from 3:30 to midnight. Sarah knew Joanne Marsh wanted to hit Avila with both barrels as soon as he walked through the door, but Sarah needed to talk to him before he realized he was in trouble. She told Marsh to hold her fire until the pharmacy tech had a chance to tell his side of the story. Marsh agreed, as long as she could be in the room when that story was told. Sarah acceded to her condition, provided that Marsh remain mum during the interview. They arranged for the pharmacy tech to be sent up to risk management when he arrived.

Sarah answered the knock on the conference room door at 3:35 to find a skinny kid with curly black hair blinking furiously and biting his lip. He reminded her of the high school boy who mowed her parents’ lawn. It was hard to fathom that this young man was the pharmacy tech whose actions had caused so much harm. Sarah showed him in and directed him to a seat at the table. She introduced herself and Doris. In keeping with their negotiated deal, Marsh said nothing. As he sat down, the young technician said, “Hello, Mrs. Marsh,” without making eye contact.

Before Sarah could give her standard introduction, Alejandro jumped the gun. “Am I in trouble? Did I do something wrong?” he asked anxiously.

“Alejandro — is it okay if I call you Alejandro?” Sarah asked.

“Sure, sure.”

“Alejandro, we’re investigating a medication error. We would very much appreciate it if you could help us out.”

“Sure, I’ll help any way I can.”

“Good. Do you remember the scripts for baby Ariel Arkin that were filled yesterday?” Sarah asked.

“No. I can’t say I do. Sorry.”

“Maybe I can help jog your memory. You delivered them in person to the pediatric wing late yesterday afternoon.”

“Oh, yeah. Now I remember. Albert — Mr. Cappelli, I mean — said they needed them in a hurry and to hightail it to the nurses’ station on Four.”

“Do you remember anything else about those scripts?”

“Just that Albert — Mr. Cappelli — said there was a glitch in the computer system, so he had to hand label one of them,” the boy explained. At that point Marsh let out an audible sigh, and Sarah gave her a warning look.

“Yeah, I ran up the stairs two at a time. When I got to peds, I handed the meds off to a blond nurse at the nurses’ station. I told her one was hand labeled because the computer system wasn’t cooperating. She thanked me and I was back in the pharmacy in no time flat.”

Sarah could see the boy start to relax as he told the story of how he’d followed his orders to the letter. She was reluctant to question the obviously well-intentioned tech about his method of stocking the shelves, but she knew that if she didn’t get to it quickly, Marsh’s fuse would likely blow.

“Alejandro, did you restock any medications yesterday?” Sarah inquired, with as much nonchalance as she could muster.

“When I came in at 3:30 yesterday, things were a little slow, so I asked Albert if I could get some of the inventory onto the shelves. He said, ‘Sure,’ so I did some restocking until things started to pick up.”

“Do you recall putting some heparin on the shelves?”

“Yeah, I sure do. It was the last thing I restocked.”

“And can you tell me how you restocked it, that is, what dosage it was and where you put it?”

“Definitely. It was a box of heparin, 10 units. I knew it was 10 units because that dose has a blue label. I learned that at my first pharmacy job back in my neighborhood.”

“And do you recall on what unit you shelved the heparin?”

“I checked the stocking guide. I don’t remember the exact number of the unit but I know it was near the front. Let me see,” he said thinking, “maybe on the third shelf. I’m trying to remember. Yeah, one of the units in the teens, like seventeen, eighteen, something like that.”

Sarah could see Marsh’s impatience grow. She had better ask the critical question. “When you restocked the heparin, what procedure did you follow?”

“Procedure? Oh, you mean the BCMA procedure?”

“Yes, the BCMA procedure.”

“Well, that’s the thing. For everything that I stocked yesterday, I followed the BCMA procedure just like I was taught and it worked perfectly. I scanned the bar code on the box and then scanned the bar code on the shelf label and everything went great. But when I scanned the bar codes for heparin 10, it wouldn’t work. I was trying to figure out why when it got real busy in the pharmacy all of a sudden. It goes like that — quiet, quiet, quiet, then all of a sudden all hell breaks loose.”

“So when it wouldn’t scan, what did you do?” Sarah asked.

“Well, I left the box on the shelf and took care of an order for Mrs. Pollack. She was one of the other pharmacists on duty yesterday.”

“Did you inform anyone of the problem with the scanning of the heparin?”

“No. I mean, I meant to, but as I said, we got really busy and we stayed busy until my shift ended at midnight. I didn’t even take a dinner break.” Looking at Marsh and then Sarah, he added in an almost plaintive voice, “I guess I forgot all about it. I’m really sorry.”

At this point Marsh broke in. “Mr. Avila. What did you learn in the training session about meds that wouldn’t scan?”

“Well, they said that if it wouldn’t scan it was probably because something was wrong.”

“Did you consider that perhaps you were making a mistake when the scanner wouldn’t accept the box of heparin on the shelf for 10 units?”

“Well, not really, since the blue label is heparin 10. I’m sure of it. And all week I’ve been hearing other people in the pharmacy say they were having trouble making the BCMA system work for them, so I figured that was the reason it wouldn’t scan,” Alejandro explained. It was evident that the logic of his thinking gave him some hope that he was not in trouble with his new boss.

Marsh was outraged. “Mr. Avila. Today we discovered the reason that the box of heparin wouldn’t scan.” With contempt dripping from each word she added, “And it had nothing to do with a BCMA system failure. The box you left on the heparin 10 shelf contained vials of 10,000 units of heparin.”

“It did?” the young man asked incredulously. “No way,” he protested. “Heparin 10 has a blue label. Blue is 10 units. It is.” He was almost pleading with Marsh.

Sarah jumped in. “Unfortunately, Alejandro, the label of heparin 10,000 is nearly an identical blue. The reason the heparin wouldn’t scan was that you stocked 10,000 rather than 10 units on the shelf.”

* * *

A scapegoat had to be found, and at the end of the interview, Alejandro Avila, the eager-to-please young pharmacy technician — a probationary, at-will employee — was told by the head pharmacist to clear out his locker and hand in his security tag. For good measure, she added that if he even thought of using her or the hospital as a reference, she would make sure he was never hired by any pharmacy in the tri-state area. For the final blow, when Avila opened the conference room door to leave, there was a security guard present to escort him out of the hospital. After he left, Joanne Marsh headed straight for John Mess’s office. Sarah guessed she was on a mission to mount an offensive, laying all the blame at the feet of Avila, and absolving the system she touted as foolproof, even in the hands of a wet-behind-the-ears pharmacy technician.

CHAPTER TEN

Sarah and Doris needed a break after the Avila interview. The two women were a study in contrasts as they made their way to the “two holer” down the hall. Sarah, tall, tailored and serious, matched her short, matronly and agreeable colleague step for step.

After coming out of the stalls, they stood side by side washing their hands. It was Doris who brought up Alejandro Avila.

“I know, Sarah. He made a terrible mistake, but I feel sorry for that young man.”

Looking at herself and Doris in the mirror, Sarah nodded as she dried her hands and pushed a lock of her dark, curly hair from her face. “He seemed like a well-meaning guy, but he set in motion a terrible chain of events.”

“True enough, but it was an honest mistake. His only real error was not asking for help when the labels wouldn’t scan. But even then, he explained how they got so busy. He probably figured he was going above and beyond by stocking the shelves when it got slow. He could have just as easily sat there playing with his phone until things picked up. You know, a lot of kids his age would have done just that. Anyway, I feel bad for him…and of course, the poor little baby, too. It’s a very sad story, any way you look at it.”