Guest Author:
Eunice Valencia, PharmD (she/her)
Eunice is a PGY-1 pharmacy resident at the Winnipeg Regional Health Authority. She received her Doctorate of Pharmacy (PharmD) from the University of Manitoba in 2024. Her residency experiences have provided her with a strong foundation in clinical practice, and she is passionate about identifying and developing strategies to optimize patient care and promote patient safety.
Medication incidents can occur when patient assessments are incomplete or rushed. Communication gaps between patients or caregivers and pharmacy teams can result in missing crucial information that affects prescribing decisions, potentially contributing to patient harm.
A Real-Life Example from a Manitoba Community Pharmacy:
A dialysis patient was prescribed valacyclovir 1 g three times daily for herpes zoster rash, instead of the renally adjusted dose of 500 mg once daily. The prescriber, busy covering a busy clinical area, overlooked the required renal dosing adjustment. The prescription was filled at a community pharmacy that was new to the patient. The pharmacy team did not determine the patient’s medical history or recognize that the medications on DPIN were those usually prescribed for dialysis patients. As a result, the patient’s renal dysfunction and the need to adjust the dose were missed. Two days later, the patient was admitted to the hospital with confusion, numbness, slurred speech, facial drooping, and was diagnosed with valacyclovir toxicity.
How Can Similar Incidents Be Prevented?
To prevent similar medication incidents from occurring, pharmacists must ensure they have all the necessary information before dispensing a prescription. When a patient presents a new prescription, a thorough review of the patient’s medical history should be conducted to determine if the prescription is appropriate for the patient.
Three Ways to Improve Patient Information Collections:
1. Standardized Patient Intake Forms
- Use a standardized intake form for new patients to gather relevant patient information, including medical conditions (e.g., renal impairment), current medications, allergies, pregnancy status, and weight.
- Consider asking patients to fill out this form ahead of time by making it available online.
2. Routinely Ask Patients
- Routinely ask patients about relevant updates regarding their diagnosis and any other health changes, such as pregnancy or new comorbidities, and update the patient profile as necessary.
- A quick checklist may be used to confirm key health information for returning patients.
3. Leverage Technology
- Explore ways to integrate technology into your dispensing software, such as requiring the allergy and medical condition fields to be completed before filling a prescription.
- Consider setting up alerts that prompt you to review lab values for certain conditions. For instance, when filling a prescription for a patient with chronic kidney disease, an alert could remind you to check their serum creatinine levels.
Other helpful SIQ blog posts highlight resources that support patient empowerment and improved care, including:
Standardized communication among healthcare providers is also essential in preventing medication incidents. For more on this topic, check out:
References:
- National Incident Data Repository for Community Pharmacies: National Snapshot. Institute for Safe Medication Practices Canada. Accessed January 13, 2025. https://ismpcanada.ca/wp-content/uploads/NIDR-National-Snapshot-July-2022.pdf.
