Every year, the College receives many complaints related to medication dispensing errors by pharmacists and pharmacy technicians. While medication errors are a major concern for the College, it is important to note that often the complainant’s secondary complaint is that the dispensing pharmacist did not appear to take responsibility or accountability for the error.
In recent complaints, patients have reported receiving the following statements after reporting the error:
“You should have checked the medications before you left the pharmacy…”
“We’re only human, what do you want us to do?”
“We’re a really busy pharmacy, mistakes happen…”
“Oh that wasn’t a serious error. You’re feeling okay right? No harm done?”
“What do you want us to do about it?”
Professional Obligations Reminder
The College would like to remind registrants of their professional and ethical obligation to act in the best interests of patients and to treat patients with respect. The accuracy and appropriateness of medication dispensed to patients is not the responsibility of the patient. When a pharmacist makes an error, it is also their professional obligation to acknowledge the error and follow up with the patient, no matter how “minor” the error may be perceived to be.
The perception that pharmacy staff did not take the patient seriously, did not appear concerned that an error occurred, or did not take any steps to prevent a recurrence is a common concern expressed in these types of complaints. Any error is a serious matter to a patient.
The College’s Inquiry Committee has made the following suggestions in past complaint cases where patients have highlighted the lack of accountability and inadequacy of follow up:
If the error is substantiated, first acknowledge that the error has occurred and apologize for the error. BC’s Apology Act makes it clear that making an apology “does not constitute an express or implied admission of fault or liability by the person in connection with that matter”;
If applicable, inform the complainant that you will contact the physician;
Assure the complainant that you will follow an action plan, and will review the pharmacy’s policies and procedures, hold a staff meeting to discuss the error, identify the reason for the error, including any systemic errors in workflow, and take steps to ensure that it does not recur; and
- Ask the complainant if the action plan addresses their primary concern and follow up with the patient once process improvement measures have been completed.
In recent cases where patient communications have been an issue, the Inquiry Committee has requested that registrants:
- At their own expense, enrol in a communications course that includes training in interpersonal skills and conflict resolution;
- Write letters of apology to the complainant;
- Re-take the online Code of Ethics tutorial on the College’s website; and/or
- Receive a letter of reprimand or a verbal reprimand from the Inquiry Committee.
Pharmacy professionals with questions on how to take accountability for and follow-up on dispensing errors can contact email@example.com.