When yes means no

when yes means no PA image

Over 10% of incidents reported to PDL involve the provision of medication to the wrong patient. The consequence of this error can result in hospitalisation or complaints made to pharmacy regulators who may take action against the pharmacist responsible.

The following extracts are taken from incident reports that have recently been filed with PDL and they demonstrate how these errors are made and the serious implications that can follow.

Case Scenario 1

“We handed out a wrong medication (Diazepam 5mg) for a customer who was waiting for his script for Flucloxacillin 500mg. I yelled out the name of the patient and the customer responded to the name, I have then passed on the medication to the assistant to charge the customer, thinking the the customer has had Diazepam in the past….”
– reporting pharmacist member of PDL 

The extract above is an example of how most of these errors occur. A consumer name is called and without further verification, the medication is provided to the first person who responds with a ‘yes’.

Another example of failure to positively identify a consumer follows;

Case Scenario 2

“The pharmacist called out the patient’s name and a person came over. The pharmacist asked if the person was collecting for Grace and she responded with a ‘yes’ and signed the prescription. Meanwhile, I had been checking another prescription. The person was asked if Grace had used it before (medication visible on bench). The person said yes. Error was discovered when the man collecting for Grace finished his phone call and walked over to collect his script, at which point dispensary technician realised the error.”
– reporting pharmacist member of PDL 

Again, closed questions have been asked by the pharmacy staff which have drawn a positive response from the patient or customer collecting on behalf of the patient, which should actually have been no. The question ‘have you used it before?’ without qualifying what you are referring to is also a pointless exercise. Open questions, as opposed to closed, should always be used and are designed to draw information from the consumer. Examples of open ended questions include; ‘Please state your address’ or, ‘May I see your Medicare card please?’ or, ‘Can you tell me what you are using the medication for?’

The implications of providing a medication to the wrong consumer can be serious. A large number of consumers take a medication without carefully reading the instructions or checking the name on the label. The ingestion of an unexpected antipsychotic or a hypnotic can lead to collapse as the following incident report shows;

Case Scenario 3

“A patient has been admitted into hospital because the DAA pack was given to the wrong patient. As the DAA pack contained a potent antipsychotic, the patient is now unconscious and is in the emergency department. The ED doctor said the patient has only taken one dose of it…”
– reporting pharmacist member of PDL 

Apart from the clinical ramifications of providing a dispensed medication to the wrong consumer, there is also the problem which presents when patient privacy has been breached. The following transcript is part of a consumer complaint which was made to a pharmacy regulator;

Case Scenario 4

The main issues I am concerned about are: 

  • Incorrect medications dispensed 
  • Breach of privacy – confidentiality and privacy of our individual health information was exposed. Our names, address, health practitioner and medications were give to the other customer, as were our scripts. 
  • The attitude of staff was dismissive in regard to this serious breach of customers receiving the incorrect medication.

– reporting consumer to pharmacy regulator 

The take home message of this PDL practice alert is that you should never trust a response of ‘YES’ to a closed question. Always follow up with an open ended question which will provide POSITIVE VERIFICATION that you are dealing with the correct consumer.

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.