Medication Safety

Institute for Safe Medication Practice, Horsham, PA

Community pharmacies are vulnerable to dispensing correctly filled prescriptions to the wrong patient at the point-of-sale. In fact, giving a correctly dispensed prescription to the wrong patient is an error scenario often shared by health care practitioners and consumers with ISMP.

Error reports

An infant was to receive Augmentin, an oral antibiotic suspension. At the pharmacy, the child’s parents were given a bag that was stapled shut with the medication inside. The prescription receipt stapled to the bag had the correct patient information.

The parents began preparing a dose at home and noticed that the consistency, smell, and amount of medication were different from previous prescriptions of Augmentin. When they looked at the pharmacy label affixed to the bottle, they realized the medication was clonidine, an antihypertensive, for a different patient.

In a second case, a prescriber ordered an antibiotic for an adolescent to treat an infection. When the patient’s mother went to their pharmacy to pick up the prescription, she was given a prescription for a different patient with a similar last name. The medication she received was Suboxone 8 mg/2 mg sublingual film, which is used to treat OUD.

The pharmacy did not review the prescription label with the mother. Believing she had received the prescribed antibiotic, the adolescent’s mother administered the Suboxone to her child. Shortly after taking the medication, the adolescent became lethargic and started vomiting. The mother looked at the prescription label and realized the medication was for a different patient. She called Poison Control who directed her to take the adolescent to the emergency department.

Recommendations to prevent harm

Always ask the patient to provide at least two patient identifiers (e.g., their full name and date of birth) when picking up prescriptions or receiving vaccines. This is important even if you “know” your patients. Compare their answer to the information in the computer system or on the prescription receipt. Never ask a “Yes” or “No” question by reading aloud the patient’s date of birth.

Employ technological enhancements at the point-of-sale (e.g., “blind” entry of patient’s date of birth) that require pharmacy staff to electronically verify the patient’s identity before the register transaction can be completed.

At the point-of-sale, review the pharmacy labels and contents of each prescription container with the patient to check that the patient’s name and medications are correct—even if this requires opening the bag. However, this may not be appropriate when a friend picks up the prescription. In these cases, patients should be notified to open the package at home, check the contents before taking any of the medication, and call the pharmacist with any concerns or questions.

Counseling the patient about their medications can also reduce the risk of the patient taking home the wrong medication. These education sessions should include a discussion of the medication’s purpose to help ensure the correct medication is being dispensed to the correct patient. As mentioned before, patient counseling at the point-of-sale may not be possible if someone other than the patient is obtaining the medication(s), so important information must be conveyed to the patient via telephone.

For additional strategies, see Best Practice #1 in the 2023–2024 ISMP Targeted Medication Safety Best Practices for Community Pharmacy. Share through the ISMP National Medication Errors Reporting Program and the ISMP Consumer Medication Errors Reporting Program. ■