Patient safety during the dispensing service in community pharmacies in the event of a prescribing error. A case report

A 63-year-old patient, diagnosed with diabetes, hypertension, and hypercholesterolemia, with myocardial infarction background who takes 9 different medications. She goes to the Community Pharmacy (CP) to pick up the prescribed treatment from the Emergency Department to treat a diagnosed conjunctivitis.

During the Dispensing Service, a potential Drug-Related Problem (DRP) of prescription error is detected, which could be related with a Negative Outcomes Related to Medicines (NOM) when prescribing ear drops for ophthalmic use, compromising patient safety .

The patient was referred to the Emergency Department to modify the treatment due to a potential risk, following the indications of the Summary of products Characteristics (SmPC). In the Emergency Department, the proposed intervention was rejected and the patient was sent back to withdraw the drug again to the CP. The patient decides to wait two days for a face-to-face medical appointment with her Primary Care Physician (MAP). The proposal made by the FC was accepted by the General Practitioner (GP).

Follow-up of the case is carried out, which allows verifying the resolution of the Health Problem as well as the DRP and NRM detected, achieving an improvement in the patient’s health and thus guaranteeing rational, safe and effective use of the medication.