This case study revolves around a 54-year-old female patient with a complex medical history who had recently begun a new pain management regimen, including a fentanyl transdermal patch (designed for long-term opioid delivery) and promethazine tablets. Upon filling prescriptions at a community pharmacy, the pharmacist mistakenly dispensed promethazine 25 mg tablets instead of the prescribed 12.5 mg tablets, and a 75 mcg/hour fentanyl patch instead of the intended 12.5 mcg/hour patch. This error occurred despite the pharmacist’s effort to convey appropriate drug information, highlighting a critical lapse during medication verification. Later, the patient applied the wrong fentanyl patch and ingested the incorrect promethazine dose. Tragically, she was found unresponsive at home and was later diagnosed with severe respiratory depression, requiring emergency intervention and a prolonged hospital stay, including a period of coma. The patient’s prior medical history did indicate past issues with opioid misuse, which complicated the medical evaluation regarding whether the outcome was directly due to the dispensing error or her prior health issues.

The root causes of the error included a combination of human oversight during the dispensing process and potentially insufficient checks within the pharmacy’s medication verification procedures. The pharmacist failed to catch the inaccuracies in the prescriptions during his review, which ultimately led to a catastrophic health outcome for the patient. A two-person verification method could have been employed where a second pharmacist or technician double-checks the prescriptions before dispensing. This can significantly reduce the likelihood of errors. Ensuring that all patient histories are updated and thorough can aid pharmacists in recognizing potential issues or drug interactions. Implementing an electronic health record (EHR) system that integrates patient histories may mitigate risks associated with manual records. Minimizing distractions in the pharmacy setting and promoting an atmosphere focused on excellence in prescription processes would contribute to better attention to detail. Continuous education regarding opioid management and safety, focusing on the implications of high doses and potential combinations with other medications like promethazine, is essential to enhance pharmacist judgment. Strengthening the communication procedures with patients, including encouraging them to ask questions and verify their understanding of medications and dosages, could prevent future errors. Conducting routine audits on pharmacy practices would help identify any systemic weaknesses and guarantee compliance with best practices. If an external reviewer or a second pharmacist had been involved in the dispensing process, the error could have been identified before it reached the patient. Additionally, implementing electronic checks for prescriptions could serve as a safeguard, catching discrepancies before medications are dispensed. Regular training sessions for pharmacy staff on the dangers of high-dose opioid combinations can also improve overall safety protocols.

If tasked with preventing the recurrence of such events, I would propose implementation of the following risk management plan. Foster a work environment that prioritizes patient safety through a no-blame culture, encouraging staff to report near misses and unsafe practices without fear of reprisal. Develop clear Standard Operating Procedures (SOPs) for medication dispensing, including the use of technology to help confirm correct dosages and patient instructions. I would mandate ongoing training in pharmacotherapy, especially focusing on high-risk medications, their safe use, and the importance of accurate dosing. Initiate a patient engagement strategy that includes patient warnings about the risks associated with certain medications to encourage patient vigilance. I would Introduce metrics to assess staff performance regarding errors and patient safety, encouraging accountability and focus on safety outcomes in practice.

In summary, this case illustrates the critical importance of risk management practices in pharmacy settings to prevent medication errors that can lead to severe harm. By implementing stronger safeguards, continuous training, and fostering an environment that prioritizes patient safety, similar incidents can be avoided in the future.

References:

Alleged dispensing of wrong medications resulting in respiratory failure, hypoventilation and permanent brain injury. (n.d.). https://www.hpso.com/Resources/Legal-and-Ethical-Issues/Alleged-dispensing-of-wrong-medications-resulting

Lewis, H. (2024, August 20). Patient safety in a ‘just culture’: Encouraging reporting and learning from errors. WTW. https://www.wtwco.com/en-us/insights/2024/08/patient-safety-in-a-just-culture-encouraging-reporting-and-learning-from-errors