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Visually confirm prescriptions with patients

October 22, 2013

Recently, ACP has investigated several complaints stemming from medication errors that all could have been avoided by confirming the patient’s identity and then visually reviewing the medication with the patient.

In each case, the pharmacy staffs had processed, prepared, and checked the prescriptions correctly. But then, the wrong patient’s prepared prescription was selected and given to another patient with a similar last name at the time of pick up. The pharmacy staff failed to remove the medication from the bag when giving it to the patient so there was no visual check by the staff or the patient.

Had the pharmacy staff confirmed the name of the patient, removed the medication from the bag, and visually confirmed the medication with the patient, these errors (and subsequent complaints) would have been avoided.

In some of these cases, the patient ingested a medication prescribed for another patient for a lengthy period and significant harm resulted.

The standards require you to confirm before releasing a prescription

Remember that the standards require the pharmacist or pharmacy technician to confirm the patient’s identity and the medication before releasing a prescription. This confirmation can only occur if, once the patient’s identity has been properly confirmed, the medication is removed from the bag and shown to the patient.

Standards reference

The Standards of Practice for Pharmacists and Pharmacy Technicians state:

8.1   Before the release of a drug or blood product provided under a prescription or the sale of a Schedule 2 drug, the pharmacist or the pharmacy technician who releases the drug or blood product must ensure communication occurs with the patient to confirm:

a) the identity of the patient;

b) the identity of the drug or blood product being dispensed or sold; and
c) refill information, if applicable.