Prescription Error Handling

Quick Answer

Immediately notify the pharmacist if the prescription hasn't been dispensed. Mark the incorrect prescription in error in SystmOne, then re-issue the correct medication after double-checking patient identity.

What Problem Does This Solve?

A wrong medication, incorrect dosage, wrong route or frequency, or a prescription for the wrong patient was issued. This guide provides a structured response to minimize clinical risk, preserve the audit trail, and ensure patient safety.

Before You Start

Prerequisites

• Access to the patient record with the incorrect prescription
• Pharmacy contact (phone or internal messaging)
• Your supervisor's contact (for high-risk medication errors)
• Familiarity with the Mark in Error workflow

Step-by-Step Instructions

1

Stop the Medication Process

Prevent the wrong medication from reaching the patient

1. Immediately notify the pharmacist if the prescription has not yet been dispensed.
2. If already dispensed, coordinate with pharmacy to retrieve or cancel the medication.
3. If the patient has already taken the wrong medication, follow your clinic's adverse event protocol.

Act Fast

Every minute counts. The sooner pharmacy is alerted, the higher the chance of intercepting the error before it reaches the patient.

2

Mark the Error in SystmOne

Preserve the audit trail by formally marking the prescription in error

1. Open the patient's record.
2. Navigate to the Medications node in the Clinical Tree.
3. Right-click on the incorrect prescription.
4. Select Mark in Error.
5. Choose the reason: "Wrong medication / dose / patient".
6. Add a detailed explanation of what was wrong and why.

Do Not Delete

Never delete a prescription. Always use Mark in Error so the audit trail is preserved.

3

Re-Issue the Correct Prescription

Enter the accurate medication details

1. Open a new prescription entry.
2. Double-check patient identity: IC number and name.
3. Enter the correct medication details:
   • Correct drug name
   • Correct dose
   • Correct frequency
   • Correct route
   • Correct duration
4. Verify before saving — review every field.
5. Save and confirm the prescription is active.

Safety Checks

• Review allergies and contraindications
• Use the drug interaction checker in SystmOne
• Confirm the prescription aligns with clinic protocols

4

Document and Communicate

Ensure all stakeholders are informed

1. Add a note in the patient's journal explaining:
   • What was prescribed in error
   • What the correct prescription is
   • Any actions taken (pharmacy notified, patient informed, etc.)
2. Inform your supervisor if the error has clinical risk implications.
3. Complete an incident report if required by clinic policy.
4. Inform the patient if they were already aware of the original prescription.

Best Practice

Don't rush during prescribing. Take time to verify patient identity, drug name, dose, route, and frequency before confirming.

Troubleshooting

Pharmacist already dispensed the wrong medication

Cause: The error was discovered after the patient received the medication.

Solution:

1. Inform the patient immediately and advise them not to take the medication.
2. Assess whether any clinical harm has occurred.
3. Document the incident thoroughly in the patient journal.
4. Notify your supervisor and follow the adverse event protocol.
5. Complete a full incident report.
6. Re-issue the correct prescription and ensure the patient understands the difference.

Cannot mark the prescription in error

Cause: The prescription may be locked, dispensed, or from another organization.

Solution:

1. If already dispensed, coordinate with pharmacy to void the dispensation first.
2. If the prescription is from another organization, use Request Mark in Error.
3. Contact your clinic administrator or ICTSO if the system blocks the action.
4. Document the error manually in the patient journal as an interim measure.

Patient was prescribed a drug they are allergic to

Cause: The allergy was overlooked during prescribing.

Solution:

1. Stop the process immediately — this is a critical safety event.
2. Notify pharmacy and the patient urgently.
3. Mark the prescription in error with reason: "Prescribed contraindicated medication — patient allergy".
4. Review the patient's allergy record and update it if incomplete.
5. Inform your supervisor and complete an incident report.
6. Re-prescribe a safe alternative after confirming no cross-reactivity.