THINK BEFORE YOU SPEAK 


 On the advice of her daughter’s psychiatrist, the mother of a severely mentally-disabled patient became her legal conservator for the purpose of managing her medications.  Knowing that her daughter didn’t drive and only had access to one pharmacy in the neighborhood, the mother went to that particular pharmacy requesting that her daughter be prevented from picking up her own prescriptions and instead, asked that all prescriptions be dispensed directly to the mother or one of her designees.  In order for the pharmacy to honor this type of request, it was necessary for the mother to furnish them with the conservatorship agreement.  This was done not once but three times in consecutive years and these instructions were ostensibly placed in the "notes" section of their computer system.  On several occasions when the mother visited the pharmacy, employees assured her that the request was in their computer system and that she had nothing to worry about.  There were even occasions in which the daughter attempted to pick up her own prescriptions and was prevented from doing so by an alert pharmacy staff who queried the computer.

The pharmacy later changed computer systems.  Although the prescription data itself automatically migrated to the new system, information contained in the “notes” section (typically allergy information and special instructions) had to be manually transferred from the old system to the new one.  Unfortunately, according to the pharmacist-in-charge at the time of the changeover, this was not done on a consistent basis.  Curiously, right around the time of the computer changeover, signature records inexplicably began showing that the patient was picking up her own medications contrary to instructions.  Despite this, the pharmacy continued to represent to the mother that everything was fine even though it obviously wasn't.

Several months later, the patient’s psychiatrist issued the patient two paper prescriptions, one for a hypnotic and another for an anxiolytic, believing that (a) the patient would simply hand the prescriptions over to her mother, and (b) even if she didn’t and attempted to fill them herself, the pharmacy would prevent this from happening just as it had on at least two previous occasions.  To everyone’s surprise and dismay, the patient was not only able to fill both prescriptions at the pharmacy where the so-called “block” was in place, she was able to fill a third prescription for a codeine-based cough suppressant (issued by another physician) at yet a different pharmacy which was not aware of the her “conserved” status.  The patient returned home, ingested the contents of all three prescriptions at the same time and arrested shortly thereafter.  Unfortunately, emergency personnel called to the scene were not able to immediately establish an airway because of aspirated material and although the patient was eventually resuscitated, she is now in a permanent vegetative state.  

There are two important takeaway points regarding the way the pharmacy handled this situation.  First, pharmacy personnel must be extremely careful when making representations to patients (or their conservators).  In this case, personnel made representations to the mother that were not completely accurate with regard to the existence of a “block” in their computer system.  While that information was in their computer system at some point, it appeared not to be in their computer system the day she was able to obtain her last two prescriptions despite the fact that no more than one month prior to the incident, pharmacy personnel assured the mother that it was.  Had pharmacy personnel actually taken the time to accurately investigate the mother’s query, the discrepancy could have easily been reconciled before the mishap occurred.  Second, pharmacies must use extreme caution when migrating information from one computer system to another.  If they are aware that some information does not automatically migrate and has to be manually moved to the new system, written policies and procedures must be put in place and enforced to facilitate this transfer of vital information.  More likely than not, this is where the information got "lost".

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