Pharmacies Response to Dispensing Errors: An Opportunity for Improved Communication

By Jill Paslier, PharmD, CSP, International Safe Medication Management Fellow at Institute for Safe Medication Practices (ISMP)

When patients report community pharmacy mediation errors to ISMP, they are often more upset by the response, or lack of response from the pharmacy staff than with the error itself. Below are a few quotes from patients, voicing their frustration with how pharmacy staff handled a potential or actual error.

“The pharmacist immediately became defensive and refused to answer questions about what I should do. He just told me I need to switch pharmacies. The pharmacist refused to file an incident/liability claim to pay for my out-of-pocket costs, which aren’t significant, but they should do the right thing.”

“The pharmacist was not concerned about my fears as a mother and neither reassured me that the changed directions would still be safe, nor did she guide me. Instead, she was defensive regarding the fact that ‘we don’t make mistakes here.’”

“I told the pharmacist that I was allergic to that and she made an ‘oops’ noise and said she would return it. No explanation. No apology. No responsibility.”

To err is human, and we all make mistakes, especially in imperfect systems. When a medication error occurs at a pharmacy, especially if a patient is harmed, pharmacy staff may experience stress, anxiety, and fear of a lawsuit. When this happens, the first response may be to deny and defend; however, this can alienate the patient and result in a missed opportunity to honestly analyze the error to discover system failures and opportunities to prevent similar errors in the future.

Instead, when pharmacy staff responds to a potential or actual error with empathy, concern, and honesty, it puts the patient’s safety first, and allows for open and honest dialogue supporting system improvements.   

Pharmacies should prepare for when (not if) errors occur, in how they will respond to the patient, and in how they will learn from the event. Below are some ways to help your pharmacy respond well to medication errors:

• Whether an error is known or only a possibility, respond immediately with concern, empathy, and compassion.
• Define staff and leadership roles and responsibilities in response to possible or actual medication errors.
• Have a written policy on how to disclose the error to patients and others (e.g., prescribers) when necessary.
• Document the event and response, including date, time, and details.
• Report the error to your organization’s internal reporting system, licensing bodies as required, and consider reporting externally to promote shared learning. (https://www.ismp.org/report-medication-error).
• Console and support staff involved in the event.
• Train staff on responding to medication errors, including role-playing scenarios in order to boost staff confidence and communication skills.
• Review the Agency for Healthcare Research and Quality (AHRQ) Communication and Optimal Resolution (CANDOR; https://www.ahrq.gov/patient-safety/capacity/candor/index.html) toolkit, which is designed to help organizations and practitioners respond to harmful events in a thorough and just manner.

In conclusion, pharmacy staff should approach all patients reporting errors or potential medication errors with transparency and empathy in order to maintain a positive relationship with the patient and allow for an honest error review and system improvements. 

References:

1. Ahrq.gov. 2018. Communication and Optimal Resolution (CANDOR). [online] Available at: https://www.ahrq.gov/patient-safety/capacity/candor/index.html [Accessed 15 March 2021].
2. ISMP. Excuse me, I think there is an error with my prescription- Practitioners should respond with empathy and honesty. ISMP Community/Ambulatory Care Medication Safety Alert! https://www.ismp.org/resources/two-new-best-practices-2020-2021-targeted-medication-safety-best-practices-hospitals. 2021; 20(2):1-4.