A failure of communication

A near miss case where a patient accidentally collected the incorrect medication highlights multiple cases of process failure, regulator says

A case from late 2020 where a patient almost left a pharmacy with medications belonging to another patients highlights the need for better communication and process checks, the Pharmacy Council of NSW says.

In a recently published case study, the Council says a regular customer, who was a pharmacist employed at the pharmacy, arrived to collect their repeat prescriptions ordered through an app.

“The shop assistant greeted her by name and went to collect the medications which were in a small basket. Seeing the assistant apparently struggling to find them, the customer also mentioned her surname. The assistant located a basket and placed the two OTC items that the customer had requested on top of the medications.

On enquiry, the customer was advised that signing for the prescriptions was not occurring because of COVID safety precautions. The customer took the basket to the cash register for payment. As the items were taken from the basket, she noticed a medication which she had not been prescribed, together with two that she took regularly.

The transaction was halted while the customer checked all the medications, and discovered a different patient’s name on all labels. She returned the medications to the dispensary and collected her own”.

The Pharmacy Council said the error occurred because of “multiple points of process failure”. These were:

  • the shop assistant knew the customer’s first name but did not know the surname
  • the customer provided her surname but the assistant seemed not to hear it clearly, which was a failure of communication (two-way)
  • the customer’s first name was an uncommon one, and coincidentally, another patient with the same first name and first letter of the surname also had medications waiting to be collected
  • the dispensed medications were covered up in the basket by requested OTC items
  • due to COVID safety precautions, the repeat forms were not required to be signed by the customer and were not in the basket, so name and address details were not checked

The council said the pharmacy did have “enough checking steps so that the error could be detected at the final check – the cash register”.

However, they pointed out that a customer less familiar with the medications, or who was distracted, may not have picked up the error as easily as a pharmacist.

“Given the fact that a number of the checkpoints failed, and particularly considering the precautions being observed during COVID, processes in the pharmacy should probably have been adjusted to account for the extra risk of error,” the Council said, recommending the following steps:

  • additional measures to ensure accurate identification of customers when collecting their medications – verbally checking the name of the customer against the name on the label, including a printed address label in the basket if the prescription forms are removed before the customer collects
  • involvement of the pharmacist in the transaction
  • showing the customer the items which were in the basket, and asking a question such as “Are these all you are collecting today?” which encourages the customer to look at the items

“The customer returned to the pharmacy the following month to collect the next supply of her medications and was pleased to see that the process was much improved and the risk of error significantly reduced,” the case study concluded.


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