Two patients, one surname: handing out to the wrong person

Introduction

The handout is the last step in dispensing and the one most often done by support staff. It is also where the wrong bag can go to the wrong person. This scenario looks at how it happens and how a thirty second check prevents it.

What happened?

Two patients with the same surname had prescriptions ready on the collection shelf. One was an older man on several regular medicines. The other was a younger man collecting a short course of antibiotics.

The younger man came in during the lunchtime rush and said his name. The counter assistant found a bag with that surname, asked 'is it for yourself?', took the payment and handed it over. He left with the older man's medicines. He did not notice until he opened the bag at home and rang the pharmacy. He had not taken anything.

The older man arrived that afternoon to find his medicines were gone. The pharmacy re-dispensed them, apologised to both patients, and the younger man returned the first bag.

What was the concern?

• The wrong medicines left the pharmacy. If the younger man had taken them, or had been less careful, the result could have been serious.
• The older man's medicines, and with them his health information, were handed to a stranger. That is a confidentiality breach as well as a safety incident.
• The only check was a surname. Under pressure, the assistant skipped the second identifier.

What was the outcome?

In this scenario the pharmacy recorded the incident, spoke to both patients, and reviewed how handout worked at busy times. It reinforced a two identifier rule for every handout, added a same-name alert sticker to bags where two patients shared a surname, and moved the collection shelf so bags could be read properly rather than grabbed. The assistant took part in the review and helped write the new checklist.

What can we learn?

1. Always confirm at least two identifiers: full name plus address or date of birth. Ask the patient to tell you, rather than reading it out for them to agree with.
2. Check the name on every item in the bag against the person, not only the bag label.
3. When someone collects for another person, check who they are collecting for and follow your pharmacy's rules on representatives.
4. Same-name patients are a known risk. Flag them.
5. A queue is not a reason to skip a check. The check takes thirty seconds. Fixing a wrong handout takes an afternoon.

Relevant pharmacy practice

Confirming identity at handout is a basic patient safety control in every pharmacy SOP. The GPhC standards for pharmacy professionals require professionals to provide person-centred care and to maintain confidentiality, and pharmacy owners must make sure support staff follow the same standards through training and SOPs.

PPets learning connection

Handing out dispensed medicines, identity checks and confidentiality are all in the Level 2 Certificate. Use this scenario to check your own handout routine against the SOP.

Record this as CPD

Registered pharmacy technicians can use this article towards GPhC revalidation, as an unplanned CPD entry or as the starting point for a reflective account. Pharmacy assistants and trainees can use it as evidence of reflective practice. Note down three things:

1. What you learned from this article
2. How you have applied it, or will apply it, in your own role
3. The benefit to the people who use your pharmacy's services

Sources and further reading

• GPhC standards and guidance for pharmacy professionals
• GPhC pharmacy team toolkit: learning from incidents

Related from PPets

• Level 2 Certificate for pharmacy support staff
• Free resources

This article is for general educational purposes only. It is not legal advice, professional regulatory advice or clinical advice about an individual patient. Always follow your pharmacy's SOPs and check current official guidance and product information.

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