In the book, \"Patient Safety for Health Professionals\", it states, \"A third-y

Question

In the book, "Patient Safety for Health Professionals", it states, "A third-year pharmacy student is employed as a pharmacy intern at a local neighboorhood community pharmacy. While working at the cash register, a client approaches. The client is a professor in the pharmacy program in which the student is enrolled. The student recognizes the professor’s face and and cordially says hello.
   The professor and pharmacy student engage in small talk about the pharmacy program at the university, and the professor tells the pharmacy student that she has come to pick up her prescription. The professor neither gives her name nor does the pharmacy student request her name. The pharmacy student walks to the “filled” prescription bins and hands her the prescription of another client. He proceeds to call her by the name “Anne.” Her name is “Linda.”
   The pharmacy professor looks down at the label on the small white paper bag. She notices that the prescription label denotes a drug for which she has had a severe allergic reaction to in the past. It is not her name on the label but the name of a colleague that is employed at the same university with an office located just three downs down the hall from her own. She promptly tells the pharmacy student that she is not “Anne.” The pharmacy student is quite embarrassed and immediately acknowledges that he mistook her for “Anne.”"
   “I’ve had several university faculty and staff come in here today.” He nervously laughs and says, “I know who you are! Here is ‘your’ prescription.”
  
   1. This is categorized as a wrong person, wrong site, and/or wrong procedure error. If you had been the pharmacy student that had committed the error, how would you have managed it?
   2. Write a narrative of this case using moral management strategies and concepts found in this chapter. How could this same error be avoided in the future? What system changes would you put in place to ensure that this does not occur again?
  

Explanation / Answer

1. First of all if I do such mistake as a intern then it is very embarrassed moment for me because I am not employee and the person to whom I give wrong prescription is my teacher. When she return me prescription telling it is not mine then I say sorry. I tell her due to name confusion such incidence happen. Then I asked detail about her like her name, DOB and address so that I make surity while handling prescription that 100% this prescription of my teacher only. Second things It is lesson for me that even a name is not essential for handling of prescription detail of individual also require for the correct prescription. After taking wrong prescription , again I check whether that lady name Anne have received another one or not. If I have doubt I call her and asked detail because simple mistake in dispatch of prescription may give permanent damage to the patient. I'll manage all my day activity smoothly now onwards and while working I stick to professionalism.

2. Whenever you are working in health care system , you must know the seriousness of profession because it give you immense pleasure while serving of patient but mistake may lead to loss of patient.

Though you have very strong emotion with the person or group of person even your family also but when it comes towards treatment and your professional , you must think that he or she is patient and to correct her abnormality is our prime moto.

I tell seriousness because your each and every step is critical and so important that you don't know.

This error avoided in future by following ways

1. Asked detail about the patient like name , birthday and full address including mobile phone numbers.

2. While giving prescription to patient check it throughout for any mistake

3. Second person check also responsible for accuracy.

4. Make detail about patient while taking prescription.

System changes

1. Classification of prescription according to disease and date of incoming of prescription

2. Use of online system for documentation so that while giving prescription chances of error is less

3. Use of barcode system e.g. when prescription come assigned it barcode and while dispatch scanned barcode so that it must match with previous one , hence there is no mistakes

4. Make availability of experience person with intern at workplace.

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