Lessons in risk minimisation: Part 2


It’s a good idea to periodically conduct risk analyses of your pharmacy’s processes and procedures, says PDL chair Dean Schulze 

This is the second installment of a two-part series. See Part 1 here.

Controlled drugs: methadone

Consider these brief cases:

  • A regular methadone patient is served by a locum pharmacist. The usual dose is 5mg however 27.5ml of 5mg/ml liquid was supplied, meaning the dose supplied was 137.5mg.
  • A methadone patient who had been absent for several days reinitiated on a new 20mg prescription. However, due to workload pressures cited, 20ml was supplied meaning the dose supplied was 100mg.

If this were to happen in your pharmacy, immediate actions should include referring the client to the nearest emergency department for observation and possible intervention, contacting the prescriber to advise them of the error and seek advice about further action.

Don’t forget to contact the client if they have left the pharmacy. Ensure they are able to have someone with them and advise them not to drive themselves to hospital.

How do we prevent this from happening in the first place? Measures could include:

  • create a dosing chart that identifies the client’s dose clearly in both milligrams and millilitres, so long as it is constantly updated;
  • endorse each prescription with the dose in millilitres for easy reference; and
  • avoid rushing especially if there is a dose change or a new client.

In both cases above the clients were hospitalised for observation though no serious intervention was required.

Dose administration aids

Consider this brief case study:

A DAA was prepared by a technician with an intended dose of 7.5mg of warfarin daily. The pack was prepared using the brown (1mg) tablets. The checking pharmacist noted 1 ½ tablets daily but did not pick up the tablets should have been green (5mg). While on the 1.5mg daily dose, the patient experienced a stroke.

This highlights the risk attached to a pharmacist checking DAAs filled by non-qualified staff. It can be dangerous to consider DAA packing more of a logistical process than a clinical issue. Mistakes with DAAs are commonly reported and the risk of adverse reaction and hospitalisation may be higher with DAA patients due to their risk profile. While non-qualified staff packing DAAs is common, procedures around training and checking of each pack must fully support this.

Another case:

A pharmacy dispenses two weeks of DAAs to a resident of an aged care facility. The patient was admitted to hospital with a cardiac condition. Her medications were changed and these changes were communicated to the pharmacy. A new DAA was prepared and sent to the facility on the patient’s return. A week after her return to the facility, the original DAA medications were packed resulting in another hospital admission.

This case reinforces the importance of updating the patient’s medication profile with the latest information. Employing good procedures and adhering to them, irrespective of the DAA system employed, is vital for safe and efficient DAA dispensing. This includes a system for retrieving incorrect or superseded packs from patients or care facilities.

Taking the time to consider and develop risk management strategies is the responsibility of all pharmacists. It’s time well spent for the health of your practice and, most importantly, your patients.

Confidential Incident Reporting/Professional Support Hotline 1300 854 838

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