Practice Insight explores concerns reported to the College as part of the complaints and reports process that present learning opportunities for pharmacists and pharmacy technicians. This close up on a complaint reminds pharmacists of their duty to provide patient counselling for new medication prescriptions, verify a medication prior to dispensing and keep clear, accurate and legible records.
Dispensing Error Accelerates Planned Surgery
A patient’s mother arrived at a pharmacy to pick up two prescriptions for her 13-year-old daughter—tramadol HCL 50mg and clarithromycin. Tramadol was to be taken if the patient’s pain could not be managed by acetaminophen and ibuprofen.
In error, the patient was dispensed trazodone HCL 50mg instead of tramadol HCL 50mg. As a result, the patient’s pain continued to worsen. The patient was admitted to the hospital and ultimately underwent necessary surgery sooner than expected.
Outcome from the Inquiries, Complaints and Reports Committee
LEARNINGS FOR REGISTRANTS
Error prevention techniques in pharmacy are geared towards optimizing public safety and patient well-being. Therefore, suitable checks and balances are in place to ensure that an error is detected prior to it being released from the pharmacy.
In the case of a prescription for a new medication, according to the Standards of Practice, the dispensing pharmacist would be required to counsel a patient at the time of the release of the medication to the patient’s custody. This discussion ensures that the drug being dispensed is the correct one, and that the dosing instructions are the same as those explained to the patient at the time the prescription was written. The pharmacist must also take this opportunity to discuss any possible side effects with the patient. This is the final opportunity for a pharmacist to correct a dispensing error, before the patient or an agent leaves the premises.
In addition, registrants must be diligent in identifying and responding to red flag situations that present in practice (Code of Ethics, section 4.9). Practice that has the potential for a high degree of harm to patients requires additional scrutiny by registrants.
Documentation is a key element of every health profession’s standard of practice and one of the most basic professional responsibilities. The Standards of Practice require that pharmacists keep clear, accurate and legible records that are consistent with applicable legislation, regulations, policies and standards. Patient records support the continuity of care and collaboration between and among health professionals. The documentation of patient care optimizes decision-making, helps to reduce duplication of services, and demonstrates the pharmacist’s decision-making process.