When medication ends up in the wrong hands

When visiting a pharmacy for a prescription of antibiotics, Sarah (not her real name) was handed a pack of methotrexate – a potent drug used to treat inflammatory conditions and various types of cancer.

Thankfully, Sarah spotted the error, handed it back to the pharmacist, and retrieved the right medication. But had the error gone unnoticed, she could have wound up with a host of medical repercussions – first, from the methotrexate; and second, from the lack of antibiotic treatment she actually required.

A common scenario

According to Jess Hadley of Pharmaceutical Defence Limited (PDL), Sarah’s scenario is not uncommon.

Having worked in the industry for seventeen years – and at PDL for three – Ms Hadley has encountered dozens of pharmacists involved in or aware of incidents where medication has been handed to the wrong person. Some patients have required hospitalisation as a result.

“Thankfully in the majority of incidents we see coming through PDL, the medication is retrieved and the consequences for the patient have been minimal,” she said ahead of the Medication Safety & Efficiency Conference.

“Usually, the pharmacist identifies something has gone wrong when the correct person comes to collect the medication; or when they see that a basket is still sitting there with medication in it. They quickly review, get in touch with the patient, and they’re usually able to rectify the situation in time.

“But unfortunately, we have seen cases where that hasn’t happened. The patient has taken the wrong meds and become unwell, or they haven’t taken the treatment they were supposed to have. And we’ve seen hospitalisations as a result of these incidents.”

As one example, Ms Hadley recalls an elderly patient rushed to the emergency department with heart palpitations, after taking a course of Ritalin that was handed to her in error by a pharmacist.

“The patient was very distressed and suffered short term health consequences. But of course, there is the potential for more severe outcomes with these types of errors.”

Repercussions for the healthcare provider

The pharmacist making the error can also experience repercussions. Depending on the context, they may face a regulatory notification, restrictions around their practice, and even civil action.

At a minimum, Ms Hadley says the pharmacist is usually very distressed.

“It can be a difficult thing to stomach when you inadvertently cause someone harm. We have heard of practitioners who have lost the will to practice after making one of these errors.

“Even in cases where no one has been harmed, some practitioners question their suitability to the role – despite the fact it is a relatively easy mistake to make.”

Causal factors

As with most medication errors, Ms Hadley says fatigue and overwork are the most likely causal factors. Equally, it could be issues around training, protocol, or experience.

“If a pharmacist or practitioner is really tired and overworked, then of course they are much more likely to make any type of medication error.

“But from my experience, these specific errors usually happen when a practitioner hasn’t been fully trained on protocol, or perhaps they don’t understand how serious it can be if protocols aren’t followed.”

Underlying this, Ms Hadley says administrative protocols – like confirming a patient’s identity – are sometimes given less weight by practitioners than clinical ones.

“We’re so focused on clinical issues, like ‘what is the right medication’, ‘is it appropriate for the person’ or ‘is the dose within therapeutic guidelines?’

“In contrast, we tend to view handing medication out and entering it into a system to be a clerical or administrative step.

“So I suppose it could be seen as a less important task – even though it’s just as important as everything else – and one people are more likely to skip if they are busy and corner cutting.”

An easy fix

With this in mind, Ms Hadley says these types of medication errors are a relatively easy fix.

“It’s really about putting emphasis on that identity confirmation step,” she said. “Making sure that every single patient confirms their identity, preferably through multiple means. For example, you could get confirmation of their name, address and condition.”

Ms Hadley also recommends that practitioners ask open-ended questions in this step.

“Rather than getting them to confirm their address with a yes or no response, you could ask them to tell you their address. It’s a small, but important, difference that would likely prevent many errors,” she said.

Further insight

Giving more advice on how practitioners and pharmacists can minimise risk through their work, Jess Hadley will present at the upcoming Medication Safety & Efficiency Conference, as part of Connect Virtual Care.

Joining her for the talk is Peter Guthrey of the Pharmaceutical Society of Australia, who will share his expert views on the litigious medication error landscape.

This year’s event will be held 2-3 April 2025 at the Hilton Sydney.

One ticket to Connect Virtual Care gives you access to three conferences: Medication Safety & Efficiency, National Telehealth and Virtual Care, and Hospital in the Home.

Learn more and register your tickets here.

About Jess Hadley

Jess Hadley is a registered pharmacist with 17 years’ experience in community pharmacy, having worked as a managing pharmacist, proprietor, and group compliance manager.

Jess is one of five PDL Professional Officers, and is on the Local Advisory Committee (LAC) for New South Wales and the Australian Capital Territory.

Her areas of interest include Schedule 8, vaccination, and proprietor legislation. She is passionate about supporting and educating pharmacists on risk minimisation and management strategies.

About PDL

PDL is Australia’s first national pharmacy body, representing over 32,000 pharmacist members, including community, hospital, credentialed and research pharmacists.

PDL provides risk management advice and practical support to its members on a wide range of practice issues. It also offers professional indemnity insurance, via a third-party underwriter.