Reducing errors one dose at a time: PDL practice alert

PDL are seeing an increase in reports of consumers being given medication which is not their own and intended for another person

In 2016, incident reports of this nature comprised around 8.5% of all reports to PDL. Risk analysis identifies this as a high rate.

If we compare processes to essential objectives for safe surgery practice, according to the World Health Organisation, universal protocol demands the medical team ensure they are operating on the correct patient at the correct site. This involves three overall steps, each comprised of multiple processes and check points.

Step 1: Verification

Multiple steps including verifying patient at point of admission or entry to theatre; again at point of transfer of patient from one person to another; again before the patient leaves the preoperative areas or enters surgical or procedure room.

Step 2: Marking

The site or sites to be operated on must be marked. Particularly important in the case of laterality, multiples structures (fingers, toes, ribs) and multiple levels (vertebral column), for example.

Step 3: ‘Time Out’ 

A ‘surgical pause’ or brief pause before the incision to confirm the patient, using a variety of verification methods including: 

  • Check that the consent form or procedure request form is correct.
  • Mark the site for the surgery or other invasive procedure.
  • Confirm identification with the patient.
  • Take a ‘team time out’ in the operating theatre, treatment or
    examination area.
  • Ensure appropriate and available diagnostic images.

As pharmacists we can learn from these steps and extract pieces useful to a pharmacy setting, where the optimum workplace environment ensures the entire pharmacy team will use methods, known to prevent harm to the patient.

A key learning found in the above is to take time to repeatedly verify and identify the script and patient (consumer).  It is not a waste of time even if you are busy. It is an essential process in implementing safe pharmacy practice and patient care to avoid errors.

A pharmacist may hand out a medication by simply calling a name and processing it for the first person that comes forward and answers yes to the name. This method of patient identification is not sufficient. A consumer may approach the counter because they misheard a name for their own; perhaps due to a willingness to agree to any posed question; speaking English as a second language or assuming it must be their turn to get their medication. 

Some names sound very similar and in fact may be the same as another consumer who is waiting. This is demonstrated by an actual excerpt from an incident report to PDL;

Case Study

A dispensary manager handed out Madopar 250mg to one of the pharmacy’s regular customers, Ms Sarah Citizen, instead of Nexium which was the prescribed medication. The incorrect medication was correctly dispensed but it was meant for another customer, Ms Sarah Civilian. As a result Ms Sarah Citizen consumed the Madopar medication and became nauseous. In extreme cases harmful side effects may include organ failure or fatality. 

In the above scenario, the dispensary manager simply called the name “Sarah” and gave it to the first person who presented without checking other details. Had the manager asked Sarah to state her address or show some photo ID, it is unlikely the error would have occurred. 

Quick tips for harm minimisation in your pharmacy

  • Is your pharmacy understaffed or do your colleagues or employees feel overworked? Promote a culture where all staff are confident to speak up and point out risky practices when they occur.
  • Ask the customer to clearly identify who they are before handing over the dispensed item. 
  • Refer to the PDL ‘Guide to Good Dispensing’ every time. Avoid being coerced into rushing or cutting corners. 
  • Use barcode scanning every time.

We can assist you with developing strategies or procedures for your pharmacy. Call us any time on 1300 854 838 or use your member login to download a copy of the “Guide to Good Dispensing”.

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  1. David Haworth

    The method we use in the pharmacy is very similar to the surgical ward. At script in ,we texta the patients name on their forehead.

  2. Philip Smith

    Any link to lower wages resulting in increased errors?

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