Risks for Prescription Drug Fulfillment

Prescription drug error fulfillment is a crucial issue in preserving the integrity of healthcare solutions. In recent times, there have been high profile cases, whereby the trust in the system has been challenged.

For example, Walgreens has been ordered by a court, to pay approximately $1.38m for its responsibility in a medical malpractice error.

This order has been passed after an investigation hearing wherein it was acknowledged that a medication four times too powerful was sold to a patient’s husband, even though the error was caught by the prescribing physician and pharmacist.

Case Study

In the Walgreens case, a patient came down with a case of food poisoning and was treated by a physician, whereby the doctor prescribed a 100ml dose of Phenergan.

Upon the patient leaving the treatment facility, the doctor recognized the mistake and contacted Walgreen to terminate the order but failed to inform the same to the patient in question.

The pharmacist at Walgreens put the prescription aside without realizing that it had already been entered into the system. Upon taking the wrong prescription, the patient began to feel disorientation in her head and was moved to emergency care with complication in her central nervous system, and subsequently lost her well-paying job because the complications precluded her from performing her duties.

The doctor did end up compensating the patient $250,000 for the mistake, and subsequently closed down her private clinic. A Walgreens representative acknowledged, through an email, that such mistakes in prescription are not common.

The spokesman confirmed that Walgreens has a multilayer integrity system to avoid such prescription related issues and are checking this case in particular given the attention it has received.

Causes

Prescription mistakes do often take place in pharmacies and in hospitals. These errors may well stem from a mistake in writing or misdiagnosis, whereby the patient experiences personal injury.

Mistakes can take place at any stage of the process because of oversight, forgetfulness, unawareness, ignorance or any other reason. It often happens in dose selection due to either poor transcription or because of bad handwriting.

Lack of knowledge or competency and a failure of complete details surrounding medicinal practices and history of patient’s treatment can cause prescription errors in terms of misdiagnosis.

An insecure workplace, difficult or uninformed policies, and lack of coordination between clinical staff, especially between physicians and nursing personnel have been found to be prime reasons behind prescription related mistakes.

Best Practices

It is highly recommended to adopt available active interventions to minimize prescription related issues. There should be proper education and training for prescribers supported by online help. The prescription procedures should be easy, automated or based on standardized prescribing charts to reduce transcription and omission mistakes.

Feedback monitoring and quick prescription review by pharmacists and through periodic audits may well also facilitate superior quality control.