Rx & The Law

Preventing The Simplest Errors

by Kenneth R. Baker, B.S.Pharm., J.D.
Vice President, General Counsel
Pharmacists Mutual Insurance Company

Every pharmacist’s greatest nightmare is discovering that a patient has been harmed because of an error from his or her pharmacy that could have been prevented.  We are all human and we can all make a mistake.  Almost every error, when analyzed later, could have been discovered before it reached a patient, or could have been avoided in the first place. 

Pharmacists Mutual’s subsidiary, PMC Quality Commitment, Inc., develops quality programs for pharmacies.  As part of these quality programs, the pharmacies track all errors and near misses through an Internet based system, which they can then use to further improve their quality and reduce errors.  For the past several months we have been learning from these records.  Some of the information is just what was expected, but some of it came as a surprise.

We had expected to find that most errors were either made at the time of computer entry or during the assembly or filling of the prescription.   During one early review we discovered twice as many mistakes were made during computer entry than were made during the filling process.  We had believed, and most pharmacists we interviewed believed, that mistakes in computer entry and in filling would have been about equal. 

We had expected, from the Pharmacists Mutual Claims Study, to find that most errors, no matter in which process they occurred, would have been either that the prescription contained the wrong drug or wrong strength of drug.  Over the years, each time we reviewed the data from the Claims Study, we found that half of all claims were caused by wrong drug and twenty-five percent were wrong strength.  What the PMC Quality Commitment, Inc. data shows, however, is that these two causes account for less than half of all prescription mistakes.   

Our greatest surprise came during an early peer review of the data.  We discovered that eight percent of all errors that reached the patient were filled exactly correctly.  The information was put into the computer correctly.  The correct drug was selected in the correct strength.  The label was right and it was placed in the correct bottle.  There should have been no problem, yet in eight percent of all errors reaching the patient, almost everything was wrong.  After doing everything right, the prescription was placed into the wrong bag. 

One reaction is that the patient should have caught the mistake and should not have taken the wrong drug.  But, in several cases the patient did take the wrong prescription. Patients trust their pharmacists.  Many patients would not consider that the bottle in the bag could be wrong.  They simply open the bag, open the bottle and, knowing from the conversation with the physician how many to take, take the correct dose – of the wrong prescription.

Pharmacists have many ways to prevent mistakes in the computer entry process and in the filling process.  How many pharmacists, however, have considered developing a method of making sure the correct bottle is in the correct bag?  How many have a way to be certain that the patient who is receiving the prescription is the right patient.

Consider a “Show & Tell” for each prescription delivered along with counseling technique using the Indian Health Service “Prime Questions”^[i].  Ask the person picking up the prescription to say to you certain information you can readily check from the receipt, such as the patient’s name and phone number or address.  Remove the prescription from the bag, read the patient’s name as it appears on the label (not the receipt) and read the directions to the patient.  Then open the bottle, show the tablet or capsule to the patient and ask, “What did your doctor tell you the medication is for?”  Follow that with “How did your doctor tell you to take the medication?”   The final question is “What did your doctor tell you to expect?”  Now, fill in the blanks in the patient’s knowledge as to the medication.  Not only is this good counseling and good pharmaceutical care, but it is also a good way to be certain that the prescription is going to the correct patient.  This is one way to prevent this “simplest” of all errors.

[i] The Indian Health Service developed “Prime Questions” counseling several years ago.  Today, almost every school of pharmacy in the United States teaches some form of this counseling technique. 

This article discusses general principles of law and risk management. It is not intended as legal advice. Pharmacists should consult their own attorneys and insurance companies for specific advice. Pharmacists should be familiar with the policies and procedures of their employers and insurance companies, and act accordingly.