PHARMACY CONNECTION ARTICLE

Focus on Error Prevention: Patient Identity

Published on: November 1, 2017 Pharmacist filling prescription in pharmacy

By Ian Stewart R.Ph, B.Sc.Phm.

I have received numerous reports of medication errors resulting from a failure to correctly identify the patient. The potential for patient harm is an obvious concern. In addition, patients receiving medications meant for another patient may also receive confidential personal health information belonging to that patient including medication history and name of their physician, along with identifying information like their name or address.

Pharmacists must be reminded that as health information custodians, we “shall take steps that are reasonable in the circumstances to ensure that personal health information in the custodian’s custody or control is protected against unauthorized disclosure”1. The inadvertent unauthorized disclosure of a patient’s private information should be seen as a privacy breach.

In some instances (such as repeated incidences of unauthorized disclosure), the health information custodian must report the privacy breach to the Ontario Information and Privacy Commissioner2.
The following cases have been reported:

Case 1:

A patient visited a walk-in clinic and received a prescription for Amoxicillin. In error, the clinic attached the incorrect patient information (name, address, phone number, health card and date of birth) to the prescription. Without looking at the prescription, the patient brought it to a local community pharmacy for processing.

The pharmacy assistant did not confirm the patient’s identity and therefore processed the prescription for the incorrect name listed on the prescription. Upon checking the prescription, the pharmacist failed to detect the error. Fortunately the error was detected when the patient returned for the medication and his name could not be found in the system.

Case 2:

Mr. Harold Smith returned to his local community pharmacy to pick up his medication. The pharmacy assistant looked into the pick-up drawer and saw a prescription bag for Harry Smith. Assuming that it is the correct patient, she retrieves the bag and quickly states “Harry Smith?”

The patient did not hear her remarks clearly and due to the similarity in names assumed that she had said Harold Smith. The incorrect medication was therefore given to the patient along with confidential information for Harry Smith. Fortunately the error was detected when the patient arrived home and the incorrect medication was not consumed.

Case 3:

A patient returned to his community pharmacy and stated that he was there to pick up his EpiPen®. The pharmacy assistant noticed an EpiPen® ready for pick up on the counter and assumed it belonged to the patient. The EpiPen® was given out to the incorrect patient.

On arriving home, the patient noticed that the EpiPen® and confidential information in the bag did not belong to him.

Recommendations:

  • When processing prescriptions, always confirm the patient’s identity by collecting the patient’s full name, their address and date of birth. There have been instances where a parent and child have the same name and live at the same address.
  • When selecting patients from a list, use extra care to ensure the correct “John Smith” is selected. Ideally, use the patient’s date of birth to ensure that the correct profile is retrieved.
  • When checking prescriptions, always confirm that the medication is being added to the correct patient profile. Confirm that all paperwork/documentation included belongs to that patient only.
  • When providing prescriptions to patients at pick up, always confirm the patient’s full name and address. Speak clearly when stating the patient’s name. Barriers to communication may include hearing deficiencies and peculiar pronunciation due to an accent.
  • Always remove any patient identifier from a product before it is returned to stock. This will prevent the inadvertent release of that information to another patient.

References:

  1. Personal Health Information Protection Act, 2004.
  2. Reporting a Privacy Breach to the Commissioner, available at: https://www.ipc.on.ca/wp-content/uploads/2017/08/health-privacy-breach-notification-guidelines.pdf
    Accessed October 4th, 2017.


Please continue to send reports of medication errors in confidence to Ian Stewart at: [email protected]. Please ensure that all identifying information (e.g. patient name, pharmacy name, healthcare provider name, etc.) are removed before submitting.

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