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Oregon News: Recent Cases Show Trend
Published in the August 2009 Oregon State Board of Pharmacy Newsletter
Cases numbered 09-0049 and 09-0219, presented during the Board’s June 2009 meeting, demonstrate a recurring, but easily preventable, dispensing error. A patient who arrived at the drivethrough window was given a lorazepam prescription that had been filled and labeled for another patient. How could this happen?
The patient for whom the prescription was labeled and the patient who received the prescription had “sound alike,” although not identical, names. When the certified pharmacy technician (CPT) read aloud the name on the container, the patient in the car nodded. When the CPT read the patient’s address, the patient in the car nodded. So the technician gave the prescription to the patient. Should be good enough, right? Not in this case because the patient received the wrong drug, somebody else’s drug.
How can this remarkably common error be prevented? The first rule to remember is, do not take shortcuts, even for the driveup/walk-up window. Open the bag and review the prescription container(s) with the patient. Ask “open-ended” questions of the patient, and confirm. Ask the patient to say and spell his or her name.
Ask the patient to state his or her address, date of birth, or other identifying information. Show the patient the prescription vial and confirm the information. Take responsibility to make sure the patient always gets the right medication in the right dose with the right information.
The Board is committed to eliminating prescribing and dispensing errors and ensuring patient safety through its evaluation, education, and enforcement activities. Also, the Board expects all pharmacists, interns, and technicians to adhere to accepted professional standards for safe and accurate medication dispensing. To this end, the Board is driven by its mission statement, “ . . . to promote, preserve and protect the public health, safety and welfare by ensuring high standards in the practice of pharmacy and by regulating the quality, manufacture, sale and distribution of drugs.”
