A Small Apology Can Go a Long Way in Pharmacy

As health care practitioners, we sometimes like to pretend we are perfect and error proof when it comes to the medication use system. However, this cannot be further from the truth; as human beings, fundamentally we are error prone. We all make mistakes—especially in the outpatient pharmacy setting, where the pharmacist is often asked to juggle multiple activities such as vaccinating, dispensing, and answering phone calls. 

When a pharmacist makes a mistake that is caught by the patient, instead of apologizing to the patient, the first instinct could be to defend their choice as right and insist the patient must be wrong. Due to fears related to job security, the punitive nature of some pharmacies, and litigation, the pharmacist may deny and deflect. This scenario can lead to the patient being frustrated and ultimately losing trust in the pharmacy. Furthermore, the health care practitioner and pharmacy team miss an opportunity to learn from this error and thus become susceptible to repeating the same error in the future. It’s time for health care practitioners to reevaluate their response to potential errors and approach it as a learning opportunity that will help increase patient safety.

The Community/Ambulatory ISMP Medication Safety Alert published in February 2022 outlines 5 steps that organizations and leadership can follow to assist staff in responding to errors with the mindset of open communication and enhanced patient safety.

Establish a Written Policy

The policy should include disclosure and apology to patients and family members. The policy should also be very detailed and should include specific guidance on what to say, what not to say, what to do, and what not to do. It should also have a clear direction regarding following up with patients.

Review and Discuss

Just having a policy in place is not sufficient. Leadership should periodically review and update the policy and procedure. Additionally, they should have discussions with the entire pharmacy team to ensure everyone is on the same page and to address any questions. 

Practice

Set aside time for staff to practice and roleplay possible interactions with patients using the established policy and procedure. 

Respond With Honesty and Empathy

When an error happens, respond immediately to the patient with compassion, empathy, and honesty. Acknowledge that a mistake has happened and follow up with plans to prevent future reoccurrence. 

Continuous Quality Improvement

Organizations should implement high leverage risk reduction strategies and view errors as learning opportunities. Research errors to determine the root cause and establish strategies to prevent future errors.