My mother-in-law, Margaret, suffers from schizoaffective disorder and chronic obstructive pulmonary disease, (COPD). Our shared family goal is that she never requires a mental health in-patient admission and so far we have achieved that goal. Let me share a story…

Margaret’s prescription for haloperidol, initially generated by a consultant psychiatrist, was issued on a three month repeat cycle. As her appointments with the consultant psychiatrist reduced in frequency, the GP took over prescribing this drug. Given that her initial prescription for haloperidol was a three month repeat prescription, my mother-in-law assumed that her GP would also provide a three month supply. A reasonable assumption to make…

One month after requesting haloperidol from the GP, the first packet of haloperidol ran out. It was a Thursday morning. My mother-in-law checked her bag of dispensed medications and realised there were no other packets of haloperidol. She had only been given one month’s supply.

So she took her repeat prescription to the GP practice, explained to the GP receptionist that the haloperidol had ran out and asked for an emergency prescription. The receptionist reminded her of the ‘48 hours to issue a prescription rule’ and told her that since she had dropped the prescription in on a Thursday afternoon and there was a bank holiday weekend coming up, she should return to collect the prescription the following Tuesday.

By Sunday, after three days without haloperidol, Margaret was starting to hear voices and her mood deteriorated. After discovering what had happened, we took her to the local community pharmacist who dispensed an emergency supply of the drug.

This story contains several lessons about system reliability, sensitivity to operations, anticipation and preparedness that the healthcare teams can learn from:

  • Why did the GP not anticipate the risk of changing the haloperidol prescription to one month’s supply?
  • Why did the pharmacist not go through the bag of dispensed drugs and explain that the haloperidol was now on a monthly repeat prescription?
  • Why did the GP receptionist not foresee the risks posed by adhering hard and fast to the ‘48 hours to issue a prescription rule’?

However, the incident contains important learning for patient and carers too. As a family, we realised that we had not struck the right balance between patient independence and sensitivity to operations (i.e. being cognisant of changes to her prescription without repeatedly asking, ‘have you taken your medication?’).

We had not anticipated what could go wrong. We had assumed reliability. We believed that she would receive her prescribed medications as and when she needed them. And when the system reliability broke down it was our preparedness in seeking an emergency supply from the community pharmacist that prevented further harm.

Learning from past events like this incident helps patients and carers to create a safe present. Several years later, I received a phone call from my fiancé. His mother was insisting, quite correctly, that her prescription should be dispensed by the community pharmacy who always dispense her medication, rather than in the supermarket pharmacy, as he was planning.

My fiancé agreed to stop off at the local community pharmacy on the way home so the prescription could be dispensed by a team familiar with her. On reviewing the prescription, the community pharmacist realised that my mother-in-law had been prescribed a contra-indicated drug. This was a good catch by the pharmacist bought about by my mother-in-law’s anticipation and preparedness.

The Health Foundation’s proposed framework for monitoring and measuring safety includes the following five dimensions: learning from past events, anticipating and thwarting emerging risks, adapting to counteract unreliable healthcare systems, showing sensitivity to operations, sharing lessons learnt through patient stories and experience.

And are these relevant to patients and carers? Simply, yes – many patients and carers are already doing these things. As healthcare professionals we need to recognise this and ask ourselves, ‘How might we empower patients and carers to enable us to learn from their experiences of measuring and monitoring safety?’

Jane is a human factors and patient safety specialist.

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