Focus on Error Prevention, Summer 2021

Focus on Error Prevention (Summer 2021)

Banner Summer 2021 - Focus on Error Prevention
Share this:

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

During the current pandemic, a large number of physicians are providing virtual healthcare. As a result, a larger number of prescriptions are being faxed into pharmacies for processing.

The lack of key patient identifiers on many faxed prescriptions along with a patient not being present when the prescription is being entered into the computer can be contributing factors to patient identity errors.


Patient: “Jane Andersen”
Drug: Zopiclone 7.5mg
Sig: One at bedtime when necessary
Mitte: 30

Patient: “James Smith”
Drug: Selegiline 5mg
Sig: One tablet at bedtime
Mitte: 30

A physician’s office faxed the above two prescriptions to a community pharmacy for processing.

At a glance, the two handwritten prescriptions looked very similar. In addition, since they were faxed and received together as page one and page two, the pharmacy assistant retrieving the prescriptions from the fax machine assumed that they were both for the same patient.

As a result, both prescriptions were scanned and entered into the profile of “Jane Andersen”, a 37-year-old patient.

The dispensing pharmacist failed to identify the computer entry error during the verification process and failed to conduct a thorough assessment of this “new” prescription against the patient’s existing medication profile. As a result, both medications were dispensed to “Jane Andersen”.

At the pick-up counter, the agent picking up the medications was a friend of the patient.

The pharmacist chose not to discuss personal information regarding the patient’s medication with a friend. A note was therefore made to call the patient later to provide counselling by telephone. However, the pharmacist forgot to follow through and the counselling never took place.

Upon receiving the two medications, the patient was puzzled why her physician would prescribe selegiline in addition to her sleeping pill. A call was made to her physician who confirmed that selegiline was never prescribed for her.

The patient then called the pharmacy to inquire why selegiline was dispensed to her when her physician never prescribed the medication.

After some investigation, the computer entry error was identified.


  • The pharmacist’s assessment of the “new” prescription was inadequate and thus did not identify the likely inappropriateness of selegeline for a 37-year-old patient.
  • Both prescriptions were faxed together. Though the patient’s name was included on both prescriptions, no other patient identifier (e.g. date of birth, health card number, etc.) was included on the prescriptions.
  • Both the pharmacy assistant and the dispensing pharmacist failed to confirm the patient’s identity.
  • Counselling did not take place largely because the medication was picked up by a friend.
  • The pharmacy does not have a process in place to communicate with patients regarding all prescriptions that are faxed in prior to processing and dispensing.


  • When assessing the prescription for appropriateness, always consider the possible indication for use. What are the possible reasons that a 37-year-old patient would take Selegiline?
  • In addition to the patient’s name, always use at least one additional patient identifier to confirm the patient’s identity at computer entry and at the pick-up counter. In this case, because the prescription was faxed in, the pharmacy may consider developing a process to contact patients who have new prescriptions sent in to obtain additional information prior to processing and performing a patient identity confirmation at the same time.
  • Develop a dependable system to identify and follow through on prescriptions requiring counselling by telephone, such as prescriptions being delivered.
  • At pick-up, always confirm the number of medications the patient is expecting to receive. Investigate any discrepancy.

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.

Please be reminded that as part of the AIMS program, pharmacists and pharmacy technicians must:

  • Anonymously record all medication incidents and near misses via the AIMS medication event reporting platform.
  • Document appropriate details of medication incidents and near misses in a timely manner to support accuracy.
  • Analyze the incident in a timely manner for causal factors and commit to taking appropriate steps to minimize the likelihood of recurrence of the incident.
  • Promptly communicate the appropriate details of a medication incident or near miss, including causal factors and actions taken as a result, to all staff.

AIMS - Focus Error Prevention


Imagine you are the pharmacist who answers the phone when the patient calls to inquire about why selegiline, which was not prescribed by her doctor, was dispensed. After remedying the situation and reassuring the patient you will look into what could have caused the mix up, you are ready to record the incident on the AIMS Pharmapod platform.

You identify the incident type as “incorrect patient” and describe briefly what happened from your perspective. If you were not directly involved with the incident, you may choose to discuss with staff members who were directly involved to gain a more thorough understanding of the incident.

Once you have a clear understanding of what took place you can begin to think about what factors may have contributed to the incident. In this case, you would select the following contributing factors in the recording platform: “critical patient information missing” (rationale: the prescriptions that were faxed in did not include the patient’s date of birth or health card number) and “lack of quality control or independent check system” (rationale: the pharmacist’s assessment of the selegiline prescription was not sufficient to identify the likely inappropriateness of this medication for a 37-year-old). Also, the pharmacy assistant processing the prescription failed to double check the name on the prescription against the profile it was entered into.) The incident recording form also includes selections for the stage of the dispensing process in which the incident occurred – in this case the primary stage is “order entry” and the secondary stage “patient communication/education.”

Thinking through the incident using the structured format of the incident recording form allows you to gain a better understanding of what happened, why it happened and where in the dispensing process it happened. This information allows for the development of impactful solutions that, once implemented, would reduce or eliminate the recurrence of similar incidents in the future. The recommendations above are examples of solutions that can be implemented in any pharmacy to prevent similar incidents. The process of thinking about medication incidents and near misses in this way promotes continuous quality improvement in your pharmacy’s work processes leading to improved patient safety and reduced patient harm. Recording incidents and near misses in AIMS also contributes towards shared learnings throughout the province and broader system improvements.

Share this: