One in ten


Source: Michael B., Flickr

One in ten errors reported to PDL involve incidents in the pharmacy where a person receives medication intended for another

Consequences include serious harm to the consumer and professional risk to the pharmacist and pharmacy owners.

A common scenario is a consumer being given the wrong dose administration aid (DAA) pack. DAA patients are often on multiple medicines and may take the medicine without checking the consumer label on the packaging due to an implicit trust in the pharmacist or pharmacy. It is the pharmacist’s responsibility to ensure the correct medication ends up in the hands of the intended consumer.

Case Study 1

Two recent cases highlight this issue with incorrect DAA packs being supplied because of similarities between the consumer names. In one case, the incorrect DAA didn’t contain the prescribed antihypertensives and the patient returned to the pharmacy feeling unwell, their blood pressure exceeded 190/120 and they were referred to hospital where the error was discovered. In the other case a patient who was not prescribed an antihypertensive received a DAA that included potent antihypertensive medicines. The consumer experienced severe hypotension and was hospitalised.

Case Study 2

In this case a methadone client was given another client’s dose. The error was not discovered until the second client presented to the pharmacy and the pharmacist identified it. This delay in identifying the error can have serious consequences, depending on the incorrect dose that was supplied. The situation led to the police being called to undertake a safety check on a client who was uncontactable after being given a higher dose. The client was distressed to have the police calling at their residence even though it was to ensure their safety.

Another scenario has recurred where a name is called and someone other than the anticipated consumer responds. The onus is on the pharmacist to complete the final important step of customer verification before handing the medication over.

Steps to help identify the consumer include:

  • Ask open ended questions. Request they state their full name or address. Alert distracted customers to engage with you to provide a full, informative answer beyond a single word.
  • Do not assume the person presenting to you is the correct client.
  • Provide counselling about the medicine.
  • Implement new procedures for stacked medicines awaiting collection to avoid medicines falling from one container to another.
  • Cross check the quantity of items on the prescription forms against the number being supplied.
  • Good procedures are vital.

Pharmacy assistants may be involved in the supply of medicines to the wrong patient. The regulators will act against the pharmacist on duty and/or the pharmacy owners. It is vital that appropriate systems and procedures have been implemented in the pharmacy to minimise the risk of errors.

Review your supply processes, update protocols where needed, consider practices that may lead to this error and act to prevent them becoming a reality.

Call PDL on 1300 854 838 for professional advice and incident risk minimisation. We are here to help you 24/7 around the clock if you experience an incident. Download The Guide to Good Dispensing via the PDL member portal.

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