Medication Safety
Institute for Safe Medication Practices, Horsham, PA
Recently, an error occurred at a health system specialty pharmacy that delivers prescriptions to onsite clinics when patients come in to meet with providers.
The program includes providing medications to patients with complex medical conditions and medications that require extra steps before they can be dispensed, such as medications with REMS requirements.
In this case, a patient with multiple myeloma was scheduled to come into the clinic to pick up Revlimid (lenalidomide) and dexamethasone. Because of the REMS requirements, prescriptions for Revlimid cannot be refilled; patients need to obtain a new prescription every month, which for this patient coincides with their clinic visits.
What happened
The patient in this case presented to the clinic, and a new prescription for Revlimid was sent to the pharmacy. The pharmacy filled the Revlimid prescription and delivered it to the patient.
However, the pharmacy technician did not deliver the patient’s dexamethasone (a nonspecialty medication) that the pharmacy had filled earlier in anticipation of the patient coming into the clinic. The filled dexamethasone prescription had been placed in the pharmacy’s will-call area, which the pharmacy technician did not realize.
When the pharmacist identified this, they called the patient at home multiple times before reaching them. Fortunately, the patient had one extra week of dexamethasone supply so they did not have a lapse in therapy.
The pharmacy’s findings
When the pharmacy investigated this event, several contributing factors were identified.
First, the pharmacy staff were focused on meeting the REMS program requirements for Revlimid and thus were less focused on the dexamethasone prescription.
Second, when prescriptions for the same patient are filled at separate times or on separate days, they may be assigned to different electronic will-call bins, which happened in this case, rather than merged into a single bin and storage location in will-call. This increases the risk that pharmacy staff miss medications placed in separate bins.
Finally, staff had developed an alternate point-of-sale (POS) workflow when delivering prescriptions to patients in clinics. The standard procedure was to scan all prescriptions at the POS to mark the prescriptions as “sold” before releasing them to the patient.
However, when delivering medications to patients in the clinic, staff did not conduct the barcode scanning step. Instead, they manually updated the system to “sold” after they delivered the prescriptions to the patient.
Staff adopted this alternate workflow because patients were not always present in the clinic when delivering the medications. If the medication must be returned to the pharmacy, it is a lengthy process to reverse the prescription from “sold” back to “ready” because, in part, the pharmacy computer system required the prescription(s) to go through the entire dispensing workflow again.
Risk-reduction strategies
Develop a standard prescription delivery process that incorporates scanning all prescriptions (e.g., at the POS) using barcode scanning technology, including prescriptions delivered as part of Meds-to-Beds programs.
Investigate the use of handheld technologies that can be brought to the clinic and enable completion of the POS transaction at the bedside.
Establish a system to verify with the clinic, before the patient leaves the pharmacy, that the patient is there to receive the medications.
Standardize processes and investigate pharmacy computer system upgrades to ensure all prescriptions for one patient are combined into one will-call bin.
Incorporate system alerts to notify staff when multiple bins contain prescriptions for the same patient. ■