The Pharmaceutical Journal Vol 264 No 7086 p371
March 4, Letters

Medication errors

Get the patient right

From Ms R. M. Bednall, MRPharmS, and Mr J. S. Semple, MRPharmS

SIR,—A core function of pharmacy is to ensure that the correct medicine is given to the correct patient. The consequences of failing to do this may be serious. We would like to report a case of hospital admission resulting from a patient taking medicines intended for someone else.
An 89-year-old man was admitted via the accident and emergency department following a fall which resulted in a fractured neck of femur. His fall was attributed to an episode of hypoglycaemia (blood sugar level of 1.3mmol/L). A drug history was obtained from medicines he had brought into hospital. This included glibenclamide and metformin at significant dosages, amlodipine and atenolol. At his previous discharge, there was no mention of diabetes mellitus or treatment for this condition. On closer examination it was obvious that the medicines were labelled for another patient and were not intended for him, although he had taken at least one dose of each of the above. The patient underwent surgery and had a prolonged period of rehabilitation in our elderly care unit.
A second incidence, in which a patient was admitted with a non-drug related problem but also with medicines labelled for another individual, has prompted us to highlight these cases.
The issues raised have implications both for community and hospital pharmacy practice. These are:

• The need to identify patients correctly, other than solely by name. (In our busy hospital outpatients department we are all too familiar with patients responding to any name)
• The importance of relating drug therapy to disease state when discussing medication. (This might have prevented the incident described above. The concept of concordance is essential for effective drug therapy as there is a group of patients who still simply comply with instructions)
• The benefit of evaluating and using patient's own medicines as part of the drug history taking process on admission and general management of medicines in hospital

While extending the roles of both hospital and community pharmacists is to be encouraged, in doing so it is important that the basic functions of care are carried out accurately.

Ruth Bednall
Senior Pharmacist, Medical Admissions

Stuart Semple
Senior Pharmacist, Elderly Care, St Thomas's Hospital, London SE1