Excuse Me, I Think There Is an Error with My Prescription: Practitioners Should Respond with Empathy and Honesty

ISMP frequently receives reports of medication errors directly from patients. Often these reports describe errors that occurred in community pharmacies. While they are understandably concerned about the errors, the patients who report to us are usually more upset about the response, or lack of response, from the pharmacist or pharmacy management team than with the actual error itself. Based on what we hear from patients and caregivers, all too often pharmacy staff, managers, and corporate personnel are leaving patients dissatisfied when addressing patients’ concerns and responding to medication errors. Below are some actual cases reported to the ISMP Consumer Medication Errors Reporting Program (CMERP):

• I picked up a prescription for temazepam to help me sleep. The pills didn’t work, and I actually felt worse taking them. Over the course of four days, I only slept about five hours total. I had heart palpitations, chest tightness, and feelings of panic and agitation. Concerned, I brought the medication back to the pharmacy and the pharmacist identified the pills as Adderall, not temazepam. The pharmacist immediately became defensive and refused to answer questions about what I should do. He just told me I need to switch pharmacies. I called my doctor who told me to go to urgent care, where I learned my heart rate and blood pressure were elevated. The pharmacist at the store 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.

• Prescription for azithromycin 100 mg/5 mL - take 1 tsp PO first day, then 1/2 tsp daily for next 4 days. Received bottle from pharmacy with label - take 5 mL PO first day, then 2.5 once daily on days 2-4. I noted that there was not enough volume to last for 5 days and that they had only put on the label to use for 4 days. I called the pharmacy concerned that the overall concentration would be higher if the entire dose was distributed over 5 days instead of 4. The answer I received from the pharmacist was that “we don’t make mistakes.” When I pointed out that the label was indeed wrong from the printed prescription, she asked me what I wanted; another bottle and proceeded to tell me that she wouldn’t be able to give it to me anyways. My concern is: 1. The pharmacist was in denial of ever making a mistake. With this mindset, they will never be aware or open to learning from mistakes made. There is such thing as human error; but the outcome of error should be learning from it. 2. My daughter did not suffer harm. However, had this been a dose sensitive drug, she (or the next patient) could have suffered. 3. I was not looking for replacement medication. Not being as familiar with the medication in its use in babies, I was fearful of the dosage being wrong. The pharmacist was not concerned about my fears as a mother and either reassuring 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 received a call this morning from the pharmacy to inform me that my prescription was ready for pickup. I called the store and was told that the prescription was for amoxicillin. 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.

Responding to a dispensing error

When medication errors happen, especially those that result in serious patient harm, practitioners can experience extreme stress and anxiety. Fear of litigation may cause healthcare organizations and practitioners to view the patient as an adversary or threat. When this happens, the organization or practitioner’s first inclination may be to deny and defend. Unfortunately, this approach can alienate patients and close the organization’s eyes to the risks that contributed to the event and patient response.

Instead, responding to victims of errors with transparency and honesty puts the patient’s safety and interests in focus. It encourages open communication about errors and supports system improvements. Most importantly, it’s the right thing to do. 

When a patient thinks a mistake has been made and brings it to the attention of a staff person, how is it handled? Who is contacted? What is the response to the patient? Are errors, including harmful events, handled with transparency, sincerity, and empathy? Does your pharmacy or organization have a policy and process for handling these situations?

Plan how to respond to an error

Every pharmacy should have written policies and procedures for handling medication errors and, more importantly, these procedures need to be reviewed and discussed with the pharmacy team, including part-time, float, and newly hired staff, so that the process is clearly understood. Regularly review the procedures for appropriateness to the specific workplace and update them to reflect changes in workflow and additions of technology. The policies and procedures should contain specific guidance about what to say and do, what not to say or do, who should be contacted, particularly when all the facts of the case may not be immediately known, and who will follow up. General principles include:

Staff Roles

• Define staff roles in response to a possible or actual medication error

• Define how management should respond and investigate the cause of an error

• For reports communicated by phone, define to whom the call should be routed and how the report is communicated internally for investigation and follow-up

Disclosure and Communication

• Have a written policy on disclosure and apology to patients and caregivers (and others as necessary) that is agreed upon and followed by management and staff

• Define when others (e.g., prescriber) should be notified of an error

• Whether the error is obvious or still a remote possibility, respond immediately with concern, compassion, and empathy

• Remedy the immediate situation with truth and honesty

• Be direct and open with the patient reporting the error; the goal is to correct the error and minimize any harm or negative impact to the patient

• Assure the patient reporting the event that it is important and a priority

• Define a process to follow-up with patients and staff to provide investigation results 

Documentation and Reporting

• Document the event and response, include the date, time, and details of the event

• Make a note in the patient’s profile so that staff is aware, especially when the patient returns to the pharmacy

• Define how and when to notify supervisors as well as risk and upper management

• Report the event using the pharmacy’s internal reporting system

• Report errors to licensing bodies as required

• Report the event confidentially to ISMP, when appropriate, to help notify others of errors that have occurred and help prevent similar errors

Staff Support

• Support staff who are involved in the incident

• Console staff and offer those involved with the error access to employee assistance programs when necessary

Staff Training

• Consider training everyone involved in responding to an error to use statements such as: “Please let me explain what we believe happened and how we plan to fix it” or “At this point, I can’t answer how this happened but I will look into it, get back to you, and let you know what we are doing to prevent this in the future” 

• Practice and role-play possible scenarios with all staff using your established procedures and guidelines. Discuss how you might respond to the following incidents:

  • A patient returns to the pharmacy counter, after just paying for his prescription, and says, “This does not look like what I got last month!”

  • While counseling a patient on their warfarin dose change, you discover that the strength on the label and the tablets in the vial don’t match

  • A patient calls the pharmacy and reports that they have received less medication than was prescribed

  • A patient calls or returns to the pharmacy reporting that they have received someone else’s medications

To help healthcare organizations and practitioners avoid adversarial type responses to harmful events, the Agency for Healthcare Research and Quality (AHRQ) published the Communication and Optimal Resolution (CANDOR) toolkit. The CANDOR process is designed to help organizations and practitioners respond to harmful events in a thorough and just manner, emphasizing transparent disclosure of adverse events and a more proactive method to achieving a fair resolution for the patient, practitioners, and organization. The process is also designed to support organizations’ efforts to fully investigate and analyze harmful events, improve safety and quality of care, and prevent patient harm. The toolkit includes multiple modules, including a disclosure checklist, to help guide organizational discussion and implementation of the CANDOR process. 

When any error happens, it is critical that pharmacies learn from them and implement high-leverage strategies to reduce or eliminate future medication errors. To maximize these efforts, establish a continuous quality improvement (CQI) program to detect, document, and assess prescription errors in order to determine the causes, develop an appropriate response, and implement strategies to prevent future errors. Share and discuss events, prevention strategies, and procedural changes with staff. It is only through analysis and investigation of root causes and contributing factors of errors that strategies to improve the medication use process and prevent future events will be identified.

Conclusion

Practitioners should approach all patients reporting actual or potential medication errors with transparency and empathy. Keep in mind that the attention and concern demonstrated to the patient and family through the admission and apology for an error as well as follow-up discussion of what will be done to prevent future occurrences can help achieve an amicable and fair resolution for all involved.