Error Alert
Institute for Safe Medication Practices, Horsham, PA
The Institute for Safe Medication Practices (ISMP) regularly receives reports from consumers that describe unprofessional and at times callous responses from pharmacists when errors or potential errors are brought to light. It is time for a change in how we interact and treat patients. It is time that we respond to consumers’ error concerns with empathy and honesty, avoiding defensive and sometimes flippant responses.
Below is a recent example reported to the ISMP Consumer Medication Errors Reporting Program:
I got my son’s prescription. I gave him his medicine the next day. I thought the pill looked different but trusted the pharmacist. The second day my son and I looked at the bottle and the description of the pill did not match the actual pill. I took the bottle to the pharmacy where the pharmacist saw my exasperated/concerned demeanor and said, “of course it’s anxiety.” EXCUSE ME?! He said the pills are correct and so I asked him why the label didn’t describe their appearance. He sighed at me and put a new corrected sticker and also a green sticker stating the pill changed. He said, “I put a new label on since it matters that much.” Again, excuse me?? I have every right to know what I put in my child’s body and to be able to verify without having to rush to the pharmacy in a panic because of mislabeling. And then being mocked and belittled. Reprehensible behavior.
Plan and practice responding to an error
When medication errors happen, especially those that result in patient harm, practitioners can experience extreme stress and anxiety. This is on top of the stress and anxiety pharmacists are already feeling related to workload, staffing shortages, and the COVID-19 pandemic. Stress combined with the fear that an error may impact job security and lead to litigation may cause health care practitioners to view the patient as a threat. When this happens, the organization’s and practitioner’s first inclination may be to deflect, deny, and defend. Unfortunately, this approach will often alienate patients and close the organization’s eyes to the risks that contributed to the event.
Instead, organizations should plan ahead and prepare staff to respond to victims of errors with transparency, honesty, and empathy. This approach puts the patient’s safety and interests in focus. It also encourages open communication about errors and supports system improvements.
Every pharmacy should have written policies and procedures for responding to medication errors, including a defined process to follow up with patients to provide investigation results. Policies on disclosure and apology to patients and caregivers (and others as necessary) are also a must. Review and discuss these policies and procedures with the entire pharmacy team so that the process is clearly understood. Regularly review the procedures for appropriateness. The policies and procedures should contain specific guidance on what to say and do, what not to say or do, who should be contacted, particularly when all the facts of the case may not be immediately known, and who will follow up. Practice and role-play possible scenarios with all staff using your established procedures and guidelines.
Conclusion
Focus on the patient and respond immediately to their report with empathy and honesty. The concern demonstrated to the patient through the acknowledgment that a mistake has occurred as well as follow-up discussion of what will be done to prevent future occurrences can help maintain healthy and compassionate communications. Most importantly, it is the right thing to do. ■