CASE STUDY #1
A patient was brought into the ER complaining of chest pains. The doctor on duty printed the PharmaNet record and prescribed drugs based on what was on her profile. When the nurse went to administer the medications, the patient stated “those don’t look like my pills”. After a lengthy discussion between the doctor and the patient, it seemed a community pharmacy was filling medications using the incorrect PHN. The doctor then called the PharmaNet Help Desk to find out where the medications on the record were being filled and followed up by calling both pharmacies involved. It was then discovered that one of the pharmacies inadvertently downloaded the incorrect patient information when setting up a local record for one of their new nursing home patients.
CASE STUDY #2
A pharmacist called the College to request that medications be transferred from an incorrect patient’s profile to the correct one. Upon review of both patients’ information, it was discovered that both PHNs belonged to the same patient. When the patient first visited the pharmacy, a pharmacist searched for the PHN, but they did not have the correct spelling of the patient’s name. When the search came back empty, he assumed that person did not have a PHN and therefore created a new one. As a result of having 2 PHNs, this patient’s medication history was incomplete on both records. The pharmacist then called the Help Desk to request PHNs be merged.
VERIFYING PHN S HELP KEEP PATIENTS SAFE
In the above cases, the medication record was incomplete and incorrect and this can ultimately impact patient care. When the PHN is not verified prior to dispensing medication, and when the PharmaNet record is not reviewed regularly, errors such as these get overlooked and this can have a negative outcome.