PDL is aware that most community pharmacies and hospitals supply or encounter dosage administration aids (DAAs). Despite their purpose to enhance compliance and minimise dosage errors, PDL still receives many reports involving incidents and errors relating to the supply of DAAs. Pharmacy owners and employed pharmacists need to be cognisant that this can be an area of high risk and therefore it is important to have well documented procedures that are adhered to. Consistently accurate packing and checking is imperative to ensure patients are not harmed.
The provision of a DAA to the incorrect patient still occurs frequently with PDL receiving reports almost every week. This can often result in poor outcomes (side effects, falls, toxicity) and/or hospitalisations as the patient not only receives the incorrect medication but also misses out on their own medications.
All medications given out by pharmacy staff should be verified using several key indicators. Simply asking a patient it if is for them or handing it to a patient that has responded to a name is insufficient. Patients in a hurry may respond to any name and often patients will have similar last names resulting in misadventure. Measures used to identify patients are more useful when asked as open-ended questions:
- What is your first and last name – you may wish to clarify spelling
- What is your address – you may wish to be less specific by asking house number or street name to protect privacy.