Operational Changes Related to Pandemic Can Open Up Risks

The coronavirus disease 2019 (covid-19) pandemic presents significant patient care and safety challenges globally and in the United States.

Necessary changes in the normal day-to-day operations of community pharmacies are designed to keep patients and pharmacy staff members safe while continuing to provide care. Two such changes include increased prescribing by telephone and moving prescription delivery away from the pharmacy counter. Although these changes can introduce the risk of medication errors, there are steps pharmacies can take to safeguard their practices.

PRESCRIPTION DELIVERY CHALLENGES

To help protect patients and staff members, pharmacies are shifting delivery of prescriptions away from the pharmacy counter. Instead, they are using curbside or home delivery (via mail). If the store already has a drive-through window, patients can pick up their prescriptions to limit contact with other customers inside the pharmacy. Although these strategies may be effective at maintaining physical distancing, they can make patient education and identification more difficult.

Like wrong-patient errors that occur at pharmacy counters, the Institute for Safe Medication Practices regularly receives, even before this pandemic, reports of these mistakes at pharmacy drive-throughs. In 1 case, a patient was given the medications intended for another person with the same birth year and name. In another report, a patient in the drive-through was given another individual’s prescription of oxycodone 20-mg tablets. The patient took 2 oxycodone tablets and was sick most of the night.

It is important to continue to use at least 2 patient identifiers: full date of birth and name. Take steps to ensure that this information is attached to prescriptions delivered by pharmacy staff members curbside or via the drive-through window to enable employees to verify the patient’s identity. When packaging prescriptions for home and mail delivery, implement a verification process to ensure that the delivery address on the delivery/shipping label matches the address in the patient’s profile and that just 1 patient’s medications are packaged together. When enrolling patients into a delivery service, confirm that the shipping address on file is correct. The Institute for Safe Medication Practices has received reports of deliveries sent to outdated addresses and packages containing medications delivered to the wrong address.

Patient education at the point of sale will not be possible if prescriptions are delivered to a location outside the pharmacy or if someone other than the patient obtains the medication. However, that does not mean that patient education should be abandoned. A reasonable effort should be made to contact patients directly to provide medication counseling, such as calling them at home or placing a written suggestion in or on the bag to call the pharmacy.

One of the most effective ways to prevent errors is to open the bag of filled prescriptions with the patient to verify that the medications are correct. Although it may not be possible to do that at the pharmacy counter during the pandemic, it is still important for patients to do this. Before patients leave the curb or drive-through, have them open the bag in the car and conduct their own verifications. If a caregiver or friend picks up a prescription or if a prescription is delivered to the patient’s home, the patient should be notified to open the package at home, check the contents before taking any of the medication, and call the pharmacist with any concerns or questions.

VERBAL COMMUNICATION ISSUES

Close, face-to-face, unobstructed communication poses risks with COVID-19. Installation of plastic or plexiglass barriers at pharmacy counters, physical distancing, and wearing masks make verbal communication more difficult. Additionally, it is recommended that prescriptions only be communicated electronically or by telephone. The same goes for refills, as patients are asked to not bring their old prescription vials into the pharmacy. It is essential to remind health care workers about the medication error risks with verbal communication and strategies to reduce those risks.

When taking orders over the telephone, the prescriber or authorized agent should be queried about allergies; comorbid conditions; date of birth; patient weight, if applicable; and purpose. Then, the patient’s date of birth and name, prescription, prescriber information, and purpose of the medication should be read back to the prescriber or agent for verification. Spell drug names back to the caller, and state numbers in digits for doses and strengths (ie, 16 should be said as “1-6,” 60 should be said as “6-zero”). Also, as the number of incoming telephone orders increases, the likelihood that prescribers will use the pharmacy’s integrated voice response system to communicate prescriptions rises. Consider adding prompts to the integrated voice response system that direct the prescriber or agent to spell all names (drug, patient, and prescriber) and spell out numbers. Finally, remind health care workers that communication is challenging when wearing masks and to speak clearly and loudly so they can be heard by the intended recipient especially those with hearing problems.

Michael J. Gaunt, PharmD, is a medication safety analyst and the editor of ISMP Medication Safety Alert! Community/ Ambulatory Care newsletter at the Institute for Safe Medication Practices in Horsham, Pennsylvania.