The patient's medication was found in another patient's bag. Both patients had the same last name.
A patient came to the community pharmacy to pick up a completed prescription request; however, the patient’s medication bag could not be located. The pharmacy computer system and the pharmacy robot’s computer system confirmed that the prescription request had been completed. Pharmacy staff then checked all the bags in the will-call area. The patient’s medication was found in another patient’s bag. Both patients had the same last name.
This is certainly not the first time we have heard of this type of error. A similar event was reported in the March 2010 issue (www.pharmacytimes.com/ publications/issue/2010/March2010/ MedicationSafety-0310) of Pharmacy Times. In that event, a patient was given another patient’s ciprofloxacin, an antibiotic. The prescription appeared to have been filled accurately but was inadvertently placed into another patient’s bag. The bag for the patient with the other patient’s medication was then placed in the will-call area and later dispensed. The error was discovered by the patient at home when she retrieved the prescription vial from the bag. Before taking the incorrect medication, she returned to the pharmacy and the error was corrected. The Institute for Safe Medication Practices (ISMP) has also seen this type of error during observations in pharmacies.
This error prompts us to call on pharmacies to review their current “bagging” procedures, because once a prescription is in the will-call area, the chances are high that a bagging error will reach the patient. Too often, verification that the correct bag and product has been retrieved from the will-call area consists only of reading the patient’s name on the pharmacy receipt stapled to the outside of the bag; this process is not sufficient. Instead, consider the following risk-reduction strategies.
For each patient, use a basket or tray to keep labeled containers and receipts together through the production process until final verification.
Strengthen strategies at the point of sale to catch bagging errors that make it to the will-call area. Staff should consistently use 2 patient identifiers at the point of sale. Ask the person picking up the prescription to provide the patient’s name and date of birth. Never ask a “yes” or “no” question by reading aloud the patient’s name or date of birth. Always ask the person to supply the information so that you can confirm it. ISMP has received numerous reports in which patients responded “yes,” confirming that the information presented was correct, only to take home someone else’s medication. Compare the person’s answers with the information listed in the computer system or printed on the prescription receipt and vial.
Incorporate a check by a staff person of each prescription vial at the point of sale, even if this requires opening the bag.
Involve the patient/customer as an additional check. Present each prescription vial to the patient to verify that each medication (and the patient’s name) is correct. While this requires some additional time at the point of sale, this step can help ensure that the right patient receives the right medication.
Employ technology at the point-of-sale register system that guides or “forces” the patient identification process. For example, consider building a blind prompt into the point-of-sale register that, when the prescription receipt is scanned, requires the pharmacy staff member to ask the customer for the birth date, and then key it into the register. If the date of birth does not match the patient’s profile or is not entered, the transaction cannot be completed.
Perform quality-control checks by observing the processes during production, during verification, and at the point of sale to ensure adherence to the standardized work practices. These checks can be done periodically by pharmacy managers and/or regional personnel.
Dr. Gaunt is a medication safety analyst and the editor of ISMP Medication Safety Alert! Community/ Ambulatory Care Edition.