T2023-01 Omission of a dose-dispensed medicine in Satakunta in the spring of 2023

A medication error occurred in Satakunta in the spring of 2023 when one medicine was omitted from a home-based patient’s prescription. The patient received most of their medicines in packages prepared using a dose-dispensing machine. Dose-dispensing units use these machines to dispense patients’ regular medication in single doses, usually for two weeks at a time.

In this case, one of the medicines prescribed for the patient was omitted when the order was sent to the dose-dispensing unit. Neither the pharmacy nor the home-care team noticed the omission, and the patient was consequently left without the medicine in question. Just under two weeks later, the patient’s health took a turn for the worse. The patient was taken to a hospital and died there two days later.

The investigation revealed that the patient’s medication was not sufficiently well established for dose dispensing. Although there were reasons to stop dose dispensing, the patient’s suitability for automated dose dispensing had not been reviewed. The existing information systems do not promote suitability assessment as well as they should. The threshold for removing a patient from the dose-dispensing scheme is high.

Sometimes dose-dispensing orders are sent through as ‘rush orders’. Some pharmacies have adopted a practice whereby they execute rush orders in a way that does not comply with the information system supplier’s instructions, which creates a risk of a medication error.

In this case, the pharmacy staff checked the medicines received from the dose-dispensing unit against the order but not against the patient’s most recent medication list. The current system of pharmacy oversight and supervision is not equipped to stop such high-risk practices. One of the objectives of the introduction of national Kanta medication lists is to make it easier for pharmacies to find each patient’s most recent medication list.

The home-care team also checked the medicines that had been received against the order and not against the up-to-date medication list. The current system of home-care oversight and supervision is therefore also not equipped to stop high-risk practices.

Both pharmacies and home-care providers collect information about patient safety incidents to improve their own operations. There has been no systematic sharing of patient safety incident reports between organisations. The National Medication Safety Programme of Community Pharmacies in Finland, launched by the Association of Finnish Pharmacies and the Finnish Centre for Client and Patient Safety, will enable the sharing of patient safety incident reports between organisations in the future.

The investigators came up with four recommendations, three of which are aimed at the Ministry of Social Affairs and Health and one at the Finnish Medicines Agency. The Safety Investigation Authority recommends that:

• The Ministry of Social Affairs and Health investigate weaknesses in the information systems that are currently used in dose dispensing and any legislation that may be needed for the competent authorities to be able to issue more detailed regulations regarding essential information system requirements.
• The Ministry of Social and Affairs ensure that patient safety incident reports concerning medication errors and lessons to be learned from such incidents are communicated effectively between pharmacies and wellbeing services counties and that clear, established procedures for sharing information are put in place.
• The Finnish Medicines Agency ensure that pharmacies adopt better self-regulation procedures to promote medication safety.
• The Ministry of Social Affairs and Health ensure that the Guide on Good Practices in Patient-specific Dispensing of Medication is updated in collaboration with the relevant authorities and operators.