The Wrong Patient incident type is a subset of dispensing incidents that continue to be highly reported to PDL. This almost entirely preventable error occurs primarily in community pharmacies; however, similar errors are also reported from hospital settings.
The potential risk for patients taking an unintended medicine is significant, especially when involving a high-risk medicine such as an opioid or narrow therapeutic index drug. Given these errors can be easily prevented through relatively simple actions, PDL has initiated a project to raise awareness and address this incident type.
PDL is releasing this alert to raise the issue and will release a second alert soon to provide greater analysis of common causes of the error and suggestions for practice change and prevention.
As part of this project, PDL is asking members to complete a survey (see below) to gather data for analysis and inclusion in further guidance that can benefit you and your patients.
Ensuring patients receive the correct medicine is crucial for all stakeholders involved. Patients and prescribers expect supply of the prescribed medicines, pharmacists and proprietors never want to cause harm to a patient, pharmacists want to avoid complaints or regulatory action, and pharmacy owners would like to reduce any risk for reputational or financial impact on their business.
PDL encourages pharmacists and pharmacy owners to include this topic in staff meetings and training activities, induction processes, and continuous quality improvement activities such as practice audits.
Wrong patient error types
The following points highlight the most common wrong patient error types reported to PDL:
- 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.
- 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.
- Scripts for multiple patients placed together for dispensing and dispensed under one name, e.g. family groups or scripts received at the same time.
- 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.
- 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.
- Vaccine incidents are reported due to confusion about the patient’s intended 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.
- Assumptions lead to errors, such as when baskets of medicines for collection contain the same or similar medicines.
- This error also occurs when labelled medicines in a refrigerator or S8 safe 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.
- Hospital pharmacists have reported wrong patient errors when clinical notes have been added to another person’s record or when a discharge profile references the wrong person.
- Prescription handling errors such as filing a prescription in another person’s file or returning repeat scripts to the wrong person.
- Delivery errors include situations where a delivery label does not match the patient’s details or current address.
- 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.
As mentioned, a follow-up alert will be released shortly with further breakdown of these incidents and suggested actions to prevent future events.
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.
Complete survey and be in the draw 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.
