ISMP Medication Error Safety Briefs

DECEMBER 21, 2017
Michael J. Gaunt, PharmD
These medication errors have occurred at least once in community pharmacies in the United States. They will happen again, perhaps where you work. Please consider sharing these stories and accounts of other errors within your organization and present them when training new and existing employees. Work with staff members to implement risk reduction strategies to prevent these errors.

Barcode your return-to-stock process. A pharmacist was verifying a prescription for rifampin 150 mg capsules. When she opened the prescription vial to visually inspect the capsules, she noticed capsules with very slight differences in appearance. Upon closer inspection, some capsules had different markings than others. The prescription had been filled with rifampin 150 mg and rifampin 300 mg capsules. It appears that a previous prescription for rifampin 300 mg capsules had been returned to stock and added back into a bottle of rifampin 150 mg.

Although the capsules and manufacturer stock bottles look similar (Figure 1), which likely contributed to the error, risk is introduced when medications are placed back into a manufacturer’s stock bottle when returning a prescription to stock. To avoid this risk, do not return medications into manufacturer stock bottles. At a minimum, keep the medications in the pharmacy prescription vial and obscure any patient- and physician-identifying information on the pharmacy label. For bulk packages (eg, topical products), remove all patient-specific labels. However, best practice calls for the pharmacy computer system to be able to generate a return-to-stock (RTS) label that includes the drug name and strength, as well as a barcode that can be scanned during production and/or verification when used to fill a subsequent prescription. Consider enhancing the RTS label by adding a description of the product. Apply the RTS label to all vials or bottles of products that are returned to stock. Develop an organizational policy for recording the expiration date on the RTS label attached to products returned to stock. Periodically review and observe the RTS process to ensure adherence.

Using open-ended questions is critical, especially for patient identification. An elderly patient mistakenly received a prescription intended for a pediatric patient. When the pharmacy clerk called out that the prescription for the child was ready, the elderly patient approached the counter. The clerk was uncertain if the prescription was actually for the elderly woman, so she asked her, “Are you here to pick up for (stated the child’s name)?” The woman answered, “yes.” After the elderly woman left the pharmacy with the wrong medication, the error was discovered. Thankfully, the pharmacy could deliver the correct medication to the woman’s home and retrieve the incorrect medication before the woman ingested any tablets. The use of closed-ended questions that have “yes” or “no” answers does not allow pharmacy staff members to accurately confirm people’s identity or assess their understanding of their drug regimen. Instead, pharmacy employees should always ask individuals to state their name and date of birth. Of course, opening the bag at the point of sale to review the medication and prescription label with the patient also would have helped catch this error.
Michael J. Gaunt, PharmD, is a medication safety analyst and the editor of ISMP Medication Safety Alert! Community/ Ambulatory Care Edition.