This column was prepared by the Institute for Safe Medication Practices, an ECRI affiliate. 

The Institute for Safe Medication Practices (ISMP) receives frequent reports of medication errors directly from patients. While patients are understandably concerned about errors, the patients who report to us are usually more upset about the response (or lack of) from the pharmacist or pharmacy management team than with the error itself. Below is a recent case reported to the ISMP Consumer Medication Errors Reporting Program: 

I got my son’s prescription. I gave him his medicine the next day. I thought the pill looked different but trusted the pharmacist. The second day my son and I looked at the bottle and the description of the pill did not match [the] actual pill. I took the bottle to the pharmacy where the pharmacist saw my exasperated/concerned demeanor and said, “of course it’s anxiety.” EXCUSE ME?! He said the pills are correct and so I asked him why the label didn’t describe their appearance. He sighed at me and put a new corrected sticker and a green sticker stating the pill changed. He said, “I put a new label on since it matters that much.” Again, excuse me? I have every right to know what I put in my child’s body and to be able to verify without having to rush to the pharmacy in a panic because of mislabeling. And then being mocked and belittled. Reprehensible behavior.

Responding to an 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 health care organizations and providers to view patients as adversaries or threats. When this happens, the 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, plan ahead and prepare staff to respond to victims of errors with transparency, honesty, and empathy. This approach puts patients’ safety and interests in focus, encourages open communication about errors, and supports system improvements.  

Every pharmacy should have written policies and procedures for responding to medication errors, including a defined process to follow up with patients to provide investigation results. Policies on disclosure and apology to patients and caregivers (and others as necessary) are also a must. Review and discuss these policies and procedures with the entire pharmacy team so that the process is clearly understood. Regularly review the procedures for appropriateness. 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. Practice and role-play possible scenarios with all staff using your established procedures and guidelines. 

It is also critical that pharmacies learn from errors and implement high-leverage risk reduction strategies. To maximize these efforts, establish a continuous quality improvement program to detect, document, and assess errors 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.  

Whether the error is obvious or still a remote possibility, focus on the patient and respond immediately with compassion, empathy, and honesty. The attention and concern demonstrated to the patient and family through the admission of an error, as well as a follow-up discussion of what will be done to prevent future occurrences, can help achieve an amicable and fair resolution for all involved. Most importantly, it is the right thing to do.