When yes means no

What error makes up 10% of incidents reported to PDL?

PDL has advised on incidents in which medication is provided to the wrong patient – a type of incident which makes up more than 10% of those reported to it.

It cites four case scenarios, taken from recent incident reports filed with PDL, which show how easily these errors can happen, and the serious potential consequences.

Case scenario 1

“We handed out a wrong medication (Diazepam 5mg) for a customer who was waiting for his script for Flucloxacillin 500mg,” a pharmacist member of PDL reported to the organisation.

“I yelled out the name of the patient and the customer responded to the name, I have then passed on the medication to the assistant to charge the customer, thinking the customer has had Diazepam in the past…”

PDL says this is an example of how most such errors occur: a patient’s name is called, and without further verification, the medication is provided to the first person who responds with a “yes”.

Case scenario 2

“The pharmacist called out the patient’s name and a person came over,” the pharmacist member of PDL reported.

“The pharmacist asked if the person was collecting for Grace and she responded with a ‘yes’ and signed the prescription.

“Meanwhile, I had been checking another prescription. The person was asked if Grace had used it before (medication visible on bench). The person said yes.

“Error was discovered when the man collecting for Grace finished his phone call and walked over to collect his script, at which point dispensary technician realised the error.”

PDL notes that again, the pharmacy staff have asked “closed” questions, which drew a positive response from the patient or the customer collecting the medicine on behalf of the patient – when the answer should have been “no”.

“The question ‘have you used it before?’ without qualifying what you are referring to is also a pointless exercise,” warns PDL.

“Open questions, as opposed to closed, should always be used and are designed to draw information from the consumer.

“Examples of open ended questions include; ‘Please state your address’ or, ‘May I see your Medicare card please?’ or, ‘Can you tell me what you are using the medication for?’”

PDL warns that there can be serious implications of providing medication to the wrong person.

“A large number of consumers take a medication without carefully reading the instructions or checking the name on the label.”

Ingesting an unexpected antipsychotic or hypnotic can lead to collapse… as the third scenario shows.

Case scenario 3

“A patient has been admitted into hospital because the DAA pack was given to the wrong patient,” said a PDL pharmacist member in reporting the incident.

“As the DAA pack contained a potent antipsychotic, the patient is now unconscious and is in the emergency department.

“The ED doctor said the patient has only taken one dose of it…”

Case scenario 4

PDL warns that apart from the clinical ramifications of providing a dispensed medication to the wrong patient, there is also the problem which presents when patient privacy has been breached.

In the fourth scenario, a consumer reported their concerns to the pharmacy regulator.

They said that the main issues concerning them included the fact that incorrect medications were dispensed; and that there had been a breach of privacy.

“Confidentiality and privacy of our individual health information was exposed,” the patient complained.

“Our names, address, health practitioner and medications were give (sic) to the other customer, as were our scripts.

“The attitude of staff was dismissive in regard to this serious breach of customers receiving the incorrect medication.”

PDL observes that pharmacists should never trust a response of “yes” to a closed question.

“Always follow up with an open-ended question which will provide positive verification that you are dealing with the correct consumer.”

PDL members can contact the organisation on 1300 854 838 if this topic raises any questions for them. PDL membership includes 24/7 access to speak with a Professional Officer for immediate advice and incident support, Australia wide.

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