"There Seems to Be a Mistake with My Prescription"

JANUARY 18, 2016
Michael J. Gaunt, PharmD
When patients report medication errors to the Institute for Safe Medication Practices (ISMP) that involve pharmacy dispensing, they are usually more upset about the response, or lack of response, from the pharmacist or pharmacy management than with the error itself. It seems that all too often pharmacy staff and managers (including corporate leaders) may be leaving patients dissatisfied. For example, here is a comment from the parent of a patient:

Amitriptyline 20 mg was the drug my daughter should have been given. Instead, the pharmacy gave her amitriptyline 200 mg. She thought this was just a change in the way it looked because a generic was dispensed. She took what was dispensed and hallucinated and spoke irrationally all night long. The next day, she was not able to function, and slept most of the day. She called the pharmacy and told them. She said the pharmacist was not very apologetic and did not want to tell her what he had given her. He said he had filled this prescription himself. He told her to bring it in, and he would exchange it. She is having her prescription transferred to another pharmacy. We know things can happen, but to the family, the pharmacist’s lack of concern was the biggest issue.

When a patient or caregiver thinks a mistake has been made and brings it to the attention of a staff person, how is it handled? Who is contacted? What is the response to the patient? Does your organization have a policy for handling these situations?

Every pharmacy should have written procedures for handling medication errors. More important, these procedures need to be read and understood by every member of the pharmacy team. The procedures should be reviewed regularly for appropriateness to the specific workplace and updated to reflect changes in work flow and technology. They should contain specific guidance about what to say and do, what not to say or do, and who should be contacted, particularly when all the facts of a case may not be immediately known. Some general principles to consider include the following:
  • Define staff roles in response to a possible or actual medication error, including a description of how staff should respond to a patient’s questions about what he or she may assume is an error in dispensing. Practice and role play possible scenarios using your established procedures and guidelines. Also define how management should respond and investigate the cause of an error.
  • Have a written policy on disclosure to patients and caregivers (and others as necessary) that is agreed on and followed by management and staff.
  • Whether an error is obvious or a remote possibility, respond immediately with concern, compassion, and empathy. Assure the patient reporting a potential or actual error that it is important and a priority.
  • Remedy the immediate situation with truth and honesty. Be direct and open with the patient reporting the error.
  • Document and report (ie, internally, to licensing bodies as required, and to the ISMP, when appropriate) the event and response.
  • Support staff members who are involved in the incident. Console them and offer those involved with an error access to employee assistance programs when necessary.
  • Establish a continuous quality improvement program to detect, document, and assess prescription errors in order to determine the cause, develop an appropriate response, and implement strategies to prevent future errors.
All alleged incidents should be handled by a pharmacist and approached with professionalism, courtesy, and sincerity. When communicating with a patient or caregiver who was involved with an incident, give the situation your undivided attention. Keep in mind that the attention and concern demonstrated to a patient and his or her family through admission of an error and appropriate follow-up may mitigate their response to the error.


Dr. Gaunt is a medication safety analyst and the editor of ISMP Medication Safety Alert! Community/ Ambulatory Care Edition.


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