A lot of probelms arise because of the fourth principle of thermodynamics.
I call it the Power of Last Authority.
I don't know how many times I have told a patient who is getting an x-ray with an urgent read, "I want you to wait at radiology after the film until I speak with you on the phone. The radiologist will give me the reading of the film. Do NOT leave UNTIL you talk to me.
Then I get the urgent read and ask to speak with the patient, and the tech tells me, "Oh, they went home." This is because the tech told them it was negative.
Same thing with pharmacy. I can tell them over and over I have just sent the prescription to your pharmacy. It will get there. But, when the pharmacy tech tells them it isn't there, they believe him or her and just assume I/We never sent it.
So, the last person they talk to is the one with the right information according to them.
