Point of sale: The last chance to get it right

ISMP error alert

In a case recently reported to the Institute for Safe Medication Practices, a patient requested a refill for zolpidem 10 mg tablets, which she takes at bedtime as needed for sleep. She was unable to pick up the medication herself, so she asked her father to do so. When he approached the pharmacy counter, he told the cashier the patient’s last name. The cashier recognized him and asked if he was picking up medications for his daughter. He said yes, and the cashier obtained the medication and completed the transaction.

Two days later, the patient called the pharmacy to inform the staff that she had received a medication intended for another patient with a similar last name. This pharmacy has a policy requiring that when a prescription is picked up, pharmacy personnel must verify the patient’s name and address. In this case, the cashier recognized the person picking up the prescription and failed to follow the policy. In doing so, she dispensed the wrong medication for the patient.

Lessons learned

When errors like this occur, the pharmacy should undertake widespread educational efforts among all personnel involved in the process, rather than remedial efforts directed at only personnel involved in the error. The pharmacy should also incorporate additional high-leverage safeguards whenever possible. Standardized systems, processes, and strategies ensure that all pharmacy staff follow the same established procedures. Consider the following strategies to help standardize processes and reduce the risk of errors at the point of sale.

Use a second patient identifier

Ask for the patient’s address or date of birth in addition to the patient’s name, and compare the answers with the information on the prescription receipt. Never ask a yes or no question by reading aloud the address or date of birth. Always ask the person to supply the information so that you can confirm it.

Open the bag

The pharmacy staff loses the opportunity for a final accuracy check when they dispense a prescription without opening the bag before the patient leaves. Ask the patient to look at the medications to verify what he or she ordered. This may not be appropriate if a friend or neighbor is picking up the patient’s prescription, however. In those cases, ask that the patients open the package at home, check the contents before taking any of the medication, and call the pharmacist with any concerns or questions.

Take advantage of technology

Existing technology can fully integrate the pharmacy management system with the point-of-sale register system. For example, consider encoding the bar code on the prescription receipt with the patient’s date of birth. When a prescription is scanned, include a blind prompt in the system that requires the pharmacy staff member to ask for and enter the customer’s birth date. If the date of birth does not match the patient’s profile or is not entered, the system will not complete the transaction.

Flag patients with similar names

Pharmacies should have electronic notes in their computer systems to warn about patients with similar names, such as those who live in the same household. Alerts should appear when these patients are selected during prescription data entry. These flags should also be visible at the point of sale.

Educate patients

Pharmacists should always engage patients by asking questions that do not entail yes or no answers. During patient education sessions, discuss the purposes of medications to help ensure the dispensation of the correct medication to the correct patient. Teach patients to participate actively in patient and medication identification processes when they pick up their medicines. This may not be possible if someone other than the patient is at the pharmacy, as mentioned above. In these cases, convey important information to the patient via telephone.

Separate drop-off and pickup areas

The pharmacy’s area designated for prescription pickup should be separate from the area dedicated to prescription drop-off. This will help prevent confusion, overcrowding, and lack of confidentiality during counseling. In a linearly designed pharmacy department, these areas might be adjacent but separated by counter dividers, signage, or colored flooring. Consider building semiprivate educational or counseling areas as design enhancements.

Quality control

Pharmacy managers should perform periodic quality control checks by observing the point of sale processes to ensure adherence to standardized practices.