A number of errors where medications are dispensed to the wrong customer are reported to Guild Insurance every year.   Of note, many of these occurred when a pharmacist dispensed scripts for two or more members of the same family.  For example, the pharmacist labelled the medications intended for a woman, with her husband’s name.

Similar errors have also occurred when pharmacists dispensed medications via dose administration aids.  For example, Webster packs were prepared correctly, but the pharmacist then put the wrong person’s label on the pack.

These errors can and do happen, even to experienced pharmacists who’ve never made a mistake before.  They can happen to you and they can have serious consequences for you and your customers.

Cases

A pharmacist was processing scripts for a customer and her husband.  The pharmacist inadvertently labelled Carvedilol 12.5mg with ‘Mr’ instead of ‘Mrs’.  As a result, the woman’s husband began taking the medication as directed.  He experienced hypotension and dizziness, causing him to fall and suffer a fractured scapula.

A number of customers were waiting for their scripts to be dispensed.  The pharmacist called out the customer’s name and a woman stepped forward and collected the script.  The customer left the pharmacy and commenced taking the medication as directed. Sometime later, the pharmacist realised that the wrong customer had taken the dispensed medication.  The customer had claimed someone else’s script for Karvea 300mg instead of the Chlorsig eye drops she had been prescribed.  Unfortunately, by the time the customer had been located she had taken the medication and suffered severe hypotension requiring hospitalisation.

Reduce the risk of dispensing errors         

• Adhere to the PDL ‘Guide to good dispensing’ every time. Don’t be coerced into rushing or cutting corners. When errors occur, pharmacists often say “if only I’d taken the time to…”
• Display posters or reminders in the dispensary to promote compliance with dispensing procedures.
• Use barcode scanning every time.
• Make use of the safety features available in your dispensing software. Set up different alerts to remind people to perform certain tasks. Likewise, make use of advanced scanning features that automatically print a barcode on the dispensing label.
• Use alert tags or signs to help distinguish between people with the same or similar surname.
• Don’t process scripts for two or more customers at once. Many errors occur when the wrong person’s labels are affixed to a medication. Don’t rely on the customer to tell you that the label is incorrect.
• Ask the customer to identify themself before handing over the dispensed item. It is not uncommon for the wrong customer to step forward and claim a script. Nor is it uncommon for a customer to say “yes” to the wrong name!
• When handing medications to a customer, point out all warnings and directions on the label and packaging. This not only helps with counselling but serves as a final check against any dispensing error.
• Reducing distractions when a pharmacist is dispensing is everyone’s responsibility. Agree to strict rules for minimising interruptions and distractions in your pharmacy.
• Promote a culture where all staff are confident to point out risky practices when they occur.

Osteopaths, like any health professionals, must take care to clearly and effectively communicate throughout the treatment process in order to avoid misunderstandings which may threaten the osteopath patient professional relationship.

An osteopath must ensure that a patient consents to each part of the treatment process, and it is important to be highly sensitive to signs that the patient is uncomfortable or has potentially withdrawn consent.

While an osteopath may be accustomed to treating patients who are in a state of undress, an individual patient may not be comfortable or understand why they are required to be in a state of undress in the presence of their health practitioner. Osteopaths have a professional responsibility to provide each patient with appropriate covering, and respond sensitively and respectfully to each patient’s needs.

Practitioners are reminded to keep discussions with patients professional at all times. Be wary about discussing personal matters. Casual comments about a patient, even where intended to make the patient feel at ease, may be misinterpreted. Conversation should be limited to topics that are appropriate in the clinical setting.

Case Scenario:

A female patient attended for the treatment of a left knee injury sustained from running. The practitioner requested the patient remove her jeans. The purpose was to allow the practitioner to examine how the patella tracked and also to assess how the tissues surrounding the patella were moving. Towels were available but not offered. The patient felt uncomfortable and could not recall the practitioner explaining why she needed to undress. The patient complained to the Australian Health Practitioner Regulation Agency (AHPRA).

The Likely Finding:

The request to remove clothing was clinically justified. The practitioner acted inappropriately by not offering some sort of covering. The practitioner also acted inappropriately by not clearly communicating the need for the patient to remove her jeans, before making the request. In all of the circumstances, the practitioner’s performance is likely to be regarded as below the standard reasonably expected of an osteopath of a similar level of training and experience.

Common Errors

Effective communication is the key to avoiding any misunderstandings on the part of patients regarding the nature and need for all aspects of their clinical care.

This article was written by Principal, Kellie Dell’Oro and Graduate Lawyer, Marianna Kirchmann. Please contact Kellie Dell’Oro if you have any questions or would like further information.

Kellie Dell’Oro
Principal

T | +61 3 9810 6775

E | kdelloro@meridianlawyers.com.au 

Case studies from practices

• A client claimed her dog was harmed as a result of a medication error. She alleged the dog suffered ‘tick poisoning’ after the practice supplied an inadequate dose of ‘tick prevention medication’. The dose given was calculated on a lower weight range than the dog’s current weight.
• A client alleged his dog died from renal failure as a result of incorrect dosing with an anti-inflammatory agent. The wrong weight had been recorded in the animal’s record. Although the dog was a small breed, a weight of 28kg was recorded. The veterinarian then used that weight to calculate the dosage, without recognising that it was unlikely to be accurate for a dog of that size.
• Guild Insurance also receives a number of similar claims every year where the cause of the incident is difficult to identify. In some instances, the veterinarian simply made a prescribing error and recorded the wrong dose or medication. In others, doses were weaned or titrated incorrectly. That is, a dose was increased when it should have been decreased, or a medication was continued long after it should have been ceased. While many of these errors result in minimal or no harm to the animal, some have had serious consequences. Errors involving prednisolone, NSAIDs or insulin have allegedly caused renal and hepatic failure. Some animals have died.

Tips for practice improvement

• The cases above serve as a timely reminder about just how easily errors can occur. Fatigue, distraction, lack of decision support tools and poorly designed work areas are all recognised as common contributing factors. Therefore, take the time to evaluate your current prescribing and dispensing practices.
  • Are you really doing everything you can to reduce the risk of error? Is your clinical workflow conducive to safe practice?  That is, do poorly designed work areas make it difficult to access things like dosing charts, calculators or product information?
  • Is your prescribing system easy to use and supportive of safe practice?  Have you considered using software with inbuilt alerts to warn you of prescribing errors?
• Always verify an animal’s weight before prescribing or dispensing medication. Weigh the animal at the time and reconcile what’s documented in the record. That is, does the recorded weight seem reasonable for the size, breed and condition of the animal? If it’s not possible to weigh the animal at the time, clarify the recorded weight with the client and again consider what is reasonable for the breed.
• Instruct staff to be particularly careful to double check and dispense the correct size of any medication. For example, 20 mg and 50 mg tablets of some popular NSAIDs may look very similar, but dispensing the wrong ones may cause disastrous consequences.
• Consider the benefits of asking another member of the practice to double check your calculation or selection, particularly if you are working under pressure or fatigued.
• To reduce the chance of inadvertently selecting the wrong medication from the shelf, introduce measures to differentiate between medications that look or sound similar. Ideas include the use of separators and flags, along with avoiding the temptation to store stock in strict alphabetical order.
• Instruct staff to point out all directions on the label and packaging when handing medications to the client. This not only helps to educate them, but serves as a final check against any error.
• Ensure staff always take the time to explain to a client what is meant by using a medication ‘off label’. There have been cases where this has not been explained to the client and they have later complained when they have read the label and seen it is not recommended for their animal.
• Use ‘alerts’ to help distinguish between the records for different animals belonging to the same client. Errors can occur when information, such as weight or test results, are inadvertently entered in the wrong record.
• Promote a culture where all staff are confident to point out risky medication practices when they occur.
• Finally, don’t believe these scenarios couldn’t happen in your practice. While the financial impact can be costly, the impact on your reputation shouldn’t be underestimated. Increasingly, people are choosing not to return to a practice once an error has occurred, instead venting their dissatisfaction via social media and the like.

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