Focus on Error Prevention

Avoiding Assumptions When Dispensing Refills

Pharmacists holding pills in hands
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By: Ian Stewart, B.Sc.Phm., R.Ph.

When processing refill prescriptions, pharmacists must complete a therapeutic check to ensure that the ongoing drug therapy is appropriate. It cannot be assumed that since the patient has taken the medication previously, a therapeutic assessment is unnecessary.

The patient profile must be reviewed to identify compliance issues, changes in drug therapy, duplicated therapy, discontinued therapy, etc. All issues identified must be investigated and resolved. This is especially important when dispensing drugs to vulnerable patients.


A ninety-three-year-old patient had been taking Valsartan 320mg once daily for an extended period of time. The patient received a three-month supply of Valsartan 320mg from her usual pharmacy.

Three months later, the patient visited their physician for a check-up. Based on results of the check-up, the physician changed the therapy to Diovan-HCT® 320/12.5mg (Valsartan-hydrochlorothiazide 320mg/12.5mg) once daily. The patient chose to obtain the new medication from an alternate pharmacy closer to the physician’s office.

After obtaining and using the three-month supply of Valsartan-HCT 320/12.5mg from the new pharmacy, the patient called the physician’s office and asked the receptionist for a refill of her “Valsartan”. As a result, the physician faxed a prescription for a further three-month supply of Diovan-HCT® 320/12.5mg to the new pharmacy. The medication was subsequently prepared and placed in the pickup drawer.

Shortly thereafter, the physician’s receptionist checked the patient’s medical record and noticed Valsartan 320mg and Diovan-HCT® 320/12.5mg. Being unaware that Diovan-HCT® 320/12.5mg was the “Valsartan” requested by the patient, the receptionist assumed that the patient was requesting a refill of Valsartan 320mg. A new prescription was therefore generated for Valsartan 320mg (with the physician’s electronic signature) and faxed to the pharmacy which had provided the Valsartan previously. The Valsartan 320mg tablets were therefore prepared and delivered to the patient.

Upon receiving the Valsartan tablets, the patient noticed that they had received the incorrect tablets. They therefore contacted the pharmacy and informed them of the error. However, the pharmacy checked the prescription and confirmed that they did dispense the correct medication as prescribed. They also checked the patient’s profile and confirmed that Valsartan 320mg was also the medication previously dispensed (they never dispensed Valsartan-HCT 320/12.5mg to the patient). The patient was therefore assured that they did indeed receive the correct medication. The patient therefore reluctantly took the Valsartan 320mg tablets.

Approximately one week later, the second pharmacy contacted the patient to remind her that the Valsartan-HCT 320/12.5mg tablets were ready for pick up. Following some discussion, the error was discovered.

Though the patient took the incorrect medication for approximately one week, no ill effects were observed.

Possible Contributing Factors:

  • Despite the patient informing the pharmacist that there was a dispensing error, the pharmacist failed to listen to the patient and investigate further.
  • The pharmacist failed to notice that the patient had last received the Valsartan 320mg tablets six months earlier.
  • The physician’s receptionist was unaware that Diovan-HCT® 320/12.5mg contained Valsartan.
  • The physician’s office failed to update the pharmacy information and therefore sent the Valsartan 320mg prescription to the previous pharmacy.
  • The physician’s computer software failed to detect the duplicate therapy and that the MD had already sent a prescription to another pharmacy.
  • The patient was utilizing multiple pharmacies.
  • The patient was vulnerable and perhaps was having difficulty advocating or vocalizing the medication related issue.


  • Always thoroughly investigate any report of a dispensing error.
  • When dispensing medications, always assess the appropriateness of the drug therapy.
  • When dispensing both new and refill prescriptions, always review the patient profile to identify any compliance issues. Prescriptions being dispensed too late or too soon can be an indication that the patient is taking the incorrect dose, drug or there is an issue that requires further investigation by the pharmacy team
  • Ensure regular check-ins with patients when new and refill prescriptions are filled, gathering information about responses to drug therapy and changes to their medical history.
  • When there are gaps in time of accessing pharmacy service care, identify these patients as possibly using multiple pharmacies and discuss the benefits of using one community pharmacy.
  • Register for access to a Clinical Viewer. Via a Clinical Viewer, pharmacists can have access to much needed health information, including prescriptions filled at other pharmacies if they were processed through publicly funded drug programs.

Please continue to send reports of medication errors in confidence to Ian Stewart at: . Sharing your experience can prevent similar occurrences at other practice sites.

Please ensure that all identifying information (e.g. patient name, pharmacy name, healthcare provider name, etc.) are removed before submitting.

<strong>Note that as part of the AIMS Program, pharmacists and pharmacy technicians must:</strong>
  • Anonymously record all medication incidents and good catches (near misses) via the AIMS Pharmapod medication event reporting platform.
  • Document appropriate details of medication incidents and good catches promptly to support accuracy.
  • Analyze the event promptly for causal factors and commit to taking appropriate steps to minimize recurrence
  • Promptly communicate the appropriate details of a medication incident or good catch, including causal factors and actions taken as a result, to all staff.

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