From the August 2007 issue

ISMP recently received a report from a patient which illustrates the wrong way pharmacists should respond to a patient’s concern about a prescription. A patient was prescribed a 3-month course of LAMISIL (terbinafine) for a superficial fungal infection. When the prescription was first dispensed, the patient received the correct medication. However, upon refill, he received ZYRTEC (cetirizine), an antihistamine, in error. Prior to leaving the pharmacy, the patient opened the prescription vial to verify that he had received the correct medication and noticed that the tablets did not look the same as those he had received the first time. The patient brought this discrepancy to the pharmacist’s attention. Unfortunately, the pharmacist responded by saying “I would not have filled it if it wasn’t correct.” The patient took the pharmacist at her word, thinking that these tablets must be a generic version of Lamisil, went home, and took the tablets as prescribed. Near the end of the 30-day supply, the patient noticed that “Zyrtec” was imprinted on the tablet. The patient returned to the pharmacy to have the prescription corrected, and the same pharmacist happened to be on duty. The pharmacist acknowledged the mistake and began correcting the prescription. While the patient was standing at the counter waiting for the pharmacist to finish, the pharmacist asked, “Are you going to look over my shoulder as I do this?” in a fashion the patient perceived as hostile and angry. The pharmacist soon finished and dispensed Lamisil. She also returned the remaining Zyrtec–which had never been prescribed–to the patient in an unlabeled prescription vial.

It is interesting to note that when consumers report medication errors to us, they are usually more upset about the response, or lack of response, they receive from the pharmacist than with the actual error. Please investigate any concerns a patient may have and seek to establish open and honest communication with them. The patient in this case was doing exactly what we most need patients to do: participate in a final check of the prescription to help prevent dispensing errors. Schools of pharmacy and community pharmacies should provide education and ongoing training to pharmacy students and personnel on how to communicate with patients and respond to errors. Responses such as those from the pharmacist in the case above will only act to drive patients away from being the final line of defense against a dispensing error.