Avoid Being the One Left Holding the Bag Containing an Error

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

Do not “hold” the verification.

A patient received the incorrect dose of digoxin for 6 months from an ambulatory care pharmacy in a community health clinic. Instead of 250 mcg daily, the patient received 125 mcg digoxin daily. The error was discovered when the prescriber sent a new prescription to the pharmacy, and the medication was filled incorrectly by a technician. When the verifying pharmacist returned the prescription to be corrected, the technician reported that the dose was the same as what the patient had taken before. It was discovered that the previous prescription had been entered and dispensed incorrectly. Both the patient and prescriber were notified. Thankfully, no adverse event was noted.

The pharmacy’s investigation of the event revealed that one cause may have been the lack of verification when the first prescription was placed “on hold” in the pharmacy computer system. When a patient presents a prescription to the pharmacy that does not need to be filled immediately (eg, a patient is already taking the medication and has refills left or may be too early to fill), it can be entered into the pharmacy computer system and placed “on hold.” This way, the patient does not need to keep track of the paper copy, and the dispensing process takes less time when the patient needs to fill that prescription. As order entry is occurring when the prescription is placed on hold, it is critical that the prescription undergoes the same verification process used when a prescription is actually dispensed. This includes conducting a double-check of the order entry by comparing the information in the computer system to that contained on the original prescription.

When the prescription is eventually dispensed, verification against the original prescription or its scanned image should be done again. Of course, final verification should include a review of the patient’s profile and a prospective drug utilization review. Engaging the patient as a final check during patient education may also have helped catch the error.

“Bagging” errors reach patients.

A patient was given another patient’s ciprofloxacin—an antibiotic—at an ambulatory pharmacy. The prescription appears to have been filled accurately but was inadvertently placed into another patient’s bag. The bag for the patient with the incorrect medication was then filed 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 any incorrect medication, she returned to the pharmacy and the error was corrected.

Once in the will-call area, the chance that the bagging error will reach the patient is almost guaranteed unless the bag is opened and checked with the patient. Too often, verification that the correct bag and product has been retrieved from will-call consists only of reading the patient name on the pharmacy receipt stapled to the outside of the bag. This process is not sufficient. In order to catch and prevent wrong-patient errors, consistently use a second identifier at the point of sale. Ask the person picking up the prescription to provide the patient’s name and address or, in the case of similar names, date of birth. Compare the answers with the information on the prescription receipt and vial.

The patient identification process cannot stop there, however. Present each prescription vial to the patient at the point of sale and have the patient verify that each medication is correct. Although this will add some additional time needed at the point of sale, this step is critical to make sure the right patient receives the right medication. â– 

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The ISMP Medication Safety Alert! Community/ Ambulatory Care Edition is a monthly compilation of medicationrelated incidents, error-prevention rec- ommendations, news, and editorial content designed to inform and alert community pharmacy practitioners to potentially hazardous situations that may affect patient safety. Individual subscription prices are $52 per year for 12 monthly issues. Discounts are available for organizations with multiple pharmacy sites. This newsletter is delivered electronically. For more information, send an e'mail message to community@ismp. org, or contact ISMP at 215-947-7797.