From the February 2009 issue

A patient was given another patient’s ciprofloxacin, an antibiotic, at an ambulatory pharmacy. The prescription appears to have been filled accurately but was inadvertently placed into another patient’s bag. The bag for the patient with the other patient’s medication was then filed in the will-call area and later dispensed. The error was discovered by the patient at home when she retrieved the prescription vial from the bag. Before taking any incorrect medication, she returned to the pharmacy and the error was corrected. Once in the will-call area, the chance that the bagging error will reach the patient is almost guaranteed unless the bag is opened and checked with the patient. Too often, verification that the correct bag and product has been retrieved from will-call consists only of reading the patient name on the pharmacy receipt stapled to the outside of the bag. This process is not sufficient. In order to catch and prevent wrong patient errors, consistently use a second identifier at the point of sale. Ask the person picking up the prescription to provide the patient’s name and address or, in the case of similar names, date of birth. Compare the answers to the information on the prescription receipt and vial. However, the patient identification process cannot stop there. Present each prescription vial to the patient at the point of sale and have the patient verify that each medication is correct. While this will add some additional time needed at the point of sale, this step is critical to make sure the right patient receives the right medication. If your site is working to prevent bagging errors, please share your ideas by e-mailing us at community@ismp.org.