PDL has recently released the Practice Alert ‘Be aware or beware of wrong patient errors – part 1’. This second alert follows up to provide greater insights into the common causes of this incident type and suggestions from PDL Professional Officers regarding preventative actions.
As part of the first alert, PDL asked members to complete a survey (see below), to gather data for analysis and inclusion in further guidance, that can benefit you and your patients. We ask that you consider responding to the survey to expand PDL’s awareness of members’ experience with this error.
PDL encourages pharmacists and pharmacy owners to utilise the information below to identify any areas of risk for this incident and to implement changes to systems to prevent future errors. Pharmacies may consider including this topic in staff meetings and training, induction processes, continuous quality improvement activities such as practice audits and other activities.
Wrong patient error types
The following points highlight several of the wrong patient error types and suggestions for prevention of the error.
- Use of closed questions to seek confirmation of the person’s identity. For example, a pharmacy assistant or pharmacist calls a patient’s name, a person steps forward, the staff member says “Mr/Ms XXX?” and the person says yes. This is not a reliable or safe means to confirm the person’s identity.
- Always use 3 points of identification such as, “Please confirm your last name/your first name/your current address/your date of birth (DOB)/your Medicare card number”.
- Patients with the same or similar names or selection of the wrong patient profile. Calling patients with similar names or inaccurate patient selection in dispensing software are commonly reported contributing factors.
- Cross check patient details against the prescription to confirm the correct patient.
- If there is an existing patient with the same name in the dispensing software double check that details such as DOB or Medicare number align, consider the medicines previously supplied and if they are likely to be prescribed for the current patient, e.g. history of antihypertensive medicines when the current script is for an antibiotic mixture.
- Utilise dispensing software warnings such as “This medicine is new for the patient” to cross check the correct patient has been selected in the software.
- Using more letters of a patient’s last name will help to narrow the search for a patient.
- Scripts for multiple patients placed together for dispensing being dispensed under one name, e.g. family groups or scripts received at the same time.
- Separate scripts for related patients within a basket, add a laminate or note to indicate multiple patients or place scripts in separate baskets within a larger basket for all family members.
- DAA errors typically involve a DAA provided to another DAA patient with a similar name or appearance. DAA errors can also occur when the completed DAA is placed into a paper bag for collection and the bag is sealed, preventing a final check. Errors can occur when medicines are entered into the wrong patient’s profile.
- Ensure DAA supply procedures includes a final check of the DAA unit and not relying on the label attached to a paper bag.
- Use three points of identification to confirm the patient’s identity when entering medicines to a patient profile and when supplying a DAA.
- Ensure delivery details match the DAA details before proceeding with delivery.
- Flag in your dispensing and DAA software systems and with all staff when DAA patients have similar names.
- Patients for whom English is not their first language, and patients with cognition issues, may be more likely to accept supply of another person’s medicine when closed questions are used.
- Examples of closed questions include “Have you had this before?” or “Are you Mr/Mrs XXX?”. Use other forms of identification e.g. drivers licence, Medicare card, a note on file that English is not well comprehended or other means to flag the communication barriers.
- Vaccine incidents have occurred when confusion about the patient’s intended vaccine has occurred.
- This could include when family members present together and there were mix-ups between vaccines indicated for certain age ranges.
- Separate different vaccines and do not place all vaccines into a singular tray.
- Use open questions to ensure booking or consent forms are cross checked to confirm patient identity and expected vaccine.
- Familiarity with opioid replacement therapy or staged supply clients may see a lapse in identity confirmation. Errors have been reported where a client with the same or similar first name is supplied with another client’s dose. Similar errors occur with supply of takeaway doses.
- Similar preventative strategies should be used as mentioned earlier for patients with similar names.
- Utilise IT systems to identify clients, and when preparing and confirming doses.
- Cross check client identity with their photo and/or DOB available in the client profile.
- Assumptions lead to errors, such as when baskets of medicines for collection contain the same or similar medicines. Similarly, errors have occurred when there are labelled medicines in a refrigerator or S8 safe that are the same or similar, and the person retrieving the medicine only sees one of those medicines and assumes it must be for the patient. This has occurred with S8s, insulins, thyroxine, vaccines and other injectable medicines.
- Never assume the correct medicine or basket has been selected. Always confirm the patient identity.
- When receiving special orders after the primary dispensing event be sure to keep a copy of the script.
- Ensure there is adequate room in the S8 safe or refrigerator to store dispensed medicines with good visibility.
- Hospital pharmacists have reported wrong patient errors when clinical notes have been added to another person’s record.
- Following hospital protocols to consistently confirm patient records is vital.
- Double checking patient details before sending documents to community pharmacies or other practitioners.
- Prescription handling errors such as filing a prescription in another person’s file or returning repeat scripts to the wrong person are simple and preventable errors.
- Check each prescription carefully before returning to a person.
- If scripts are retained at the pharmacy, use a system to separate the scripts from other patient’s files and ensure patient details are clearly marked for easy identification.
- If there are patients with the same or similar names, add a warning message about the similarity and the need to double check patient details.
- Delivery errors include situations where a delivery label does not match the patient’s details or current address.
- When deliveries are being arranged always ask the patient to confirm the correct delivery address, rather than state the assumed address and ask if that is correct, as this is a closed question and can lead to error.
- Confirm with the patient if they give permission for an agent to receive the delivery and note who the person may be in the delivery notes.
- Ensure staff or contractors undertaking delivery record the identity of the person receiving the delivery, especially if the person receiving is an agent.
- PDL strongly urges pharmacies to avoid leaving deliveries if the patient or an agreed agent is not available.
- Other contributing factors identified from incident reports include workload and staff capacity pressures leading to lapses in correct patient identification and an absence of appropriate counselling.
- Taking time with each patient and giving patients a clear understanding of wait times can minimise pressure on staff.
- Lack of appropriate counselling.
- Counselling on the medicine supplied, including confirming the indication, is an opportunity to confirm the patient’s identity. PDL reports indicate that absence of counselling is a factor in many wrong patient incidents.
Resources to prevent wrong patient errors
PDL resources that can assist in preventing wrong patient errors include the Guide to Good Dispensing, which is available to members in the Guides and Resources section of the PDL member portal.
Furthermore, PDL has developed a Reflective Practice Activity which is available on the AJP website. This activity is CPD-accredited and Group 3 CPD points may be achieved by a pharmacist applying the audit activity and assessing practice change following the training and audit activities.
Reminder to complete survey and be in to win
As part of the awareness activity, the PDL Professional Officers have developed a short survey to better understand pharmacists’ experiences of wrong patient near misses* and incidents.
In better understanding the frequency and circumstances around wrong patient error types, PDL hopes to provide more tailored support for pharmacists in mitigating and managing this error type. Members who complete this survey have the option to enter a random draw to win one of five $100 Flexi eGift Cards as a recognition of the time and information offered.
Survey closes on Sunday, 6 October 2024.
*PDL considers a near miss to be an error that is identified and rectified before the patient becomes aware of the mistake.
For immediate advice and incident support, call PDL on 1300 854 838 to speak with one of our Professional Officers. We are here to support our pharmacist members 24/7, Australia-wide
