Open the Bag to Catch Errors at the Point of Sale

Giving a correctly dispensed prescription to the wrong patient is a common error in community pharmacies. In fact, it is the most common complaint the Institute for Safe Medication Practices (ISMP) receives through the National Consumer Medication Errors Reporting Program. Roughly one-fourth of the events ISMP receives involve patients ingesting the wrong medication. These reports are only the “tip of the iceberg,” as a study conducted by ISMP found that this error happens about once for every 1000 prescriptions dispensed.¹ With close to 4 billion prescriptions dispensed each year, an average of 7 errors happens each month at every pharmacy across the United States.

HOW ERRORS HAPPEN

Giving a correctly filled prescription to the wrong patient can happen for several reasons, including:

• Pharmacy staff places the patient’s medication in a bag intended for another patient, often stemming from working on more than one patient’s prescription at a time.
• Pharmacy staff does not ask for, or verify, the patient’s full name and date of birth at the point of sale.
• Pharmacy staff selects the wrong patient’s bag from the will-call area, possibly due to similar or the same first and/or last names.

CONSEQUENCES OF ERRORS

Taking a contraindicated medication. If your patient does not notice the error and takes another patient’s medication, it could be a medication to which the patient has a contraindication; for example, a pregnant woman who intended to fill a prescription for an antibiotic to treat an infection but was accidentally given another woman’s prescription for methotrexate. Both women had the same last name and very similar first names.

Omission of the correct medication. Another problem with receiving and taking the wrong patient’s medication is that the patient actually ingesting the drug may not be taking their prescribed medication. This can lead to untreated health conditions that worsen over time or other adverse effects. Misuse of the incorrect medication. Patients who are accidentally given the wrong patient’s medications have occasionally misused these medications for recreational purposes or to harm themselves. In one case, a patient went to the pharmacy to pick up his prescriptions but was given another patient’s allergy medication and oxyCODONE, an opioid pain reliever. When the patient was called, he denied receiving the wrong prescriptions, presumably because of the oxyCODONE—a common drug of abuse.

Breach of protected health information. Another consequence of this type of error is that confidential information is accidentally disclosed to the person who receives someone else’s medication.

RECOMMENDATIONS TO PREVENT HARM

Although community pharmacies can implement several safeguards to detect wrong patient errors, 3 relatively simple steps can practically eliminate the risk of a patient taking home another patient’s medication by mistake¹:

• At the point of sale, have patients review the pharmacy labels and contents of each prescription container to check that the medication is correct— even if this requires opening the bag. This step alone can cut in half the risk of patients taking home a correctly filled prescription intended for another patient.
• Always ask patients to provide 2 identifiers—their full name and date of birth—when picking up prescriptions. This is important even if you “know” your patients. Compare their answer to the information in the computer system or on the prescription receipt. Never ask a yes-or-no question by reading aloud the patient’s date of birth. This step reduces by one-third the risk of the wrong medication going home with the wrong patient.
• Talking to patients about their medications reduces by another 25% the risk of taking home the wrong medication. Patient education sessions should include a discussion of the medication’s purpose to help ensure the correct medication is being dispensed to the correct patient.

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

Reference

• Cohen MR, Smetzer JL, Westphal JE, Comden SC, Horn DM. Risk models to improve safety of dispensing high-alert medications in community pharmacies. J Am Pharm Assoc. 2012;52(5):584-602.