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Student Practice Case—Student Facilitator Guide

Scenario

Information provided to student

You are the pharmacist-in-charge at a community pharmacy. While working your shift on a particularly busy day, you receive a call from a patient stating that their medication looks different from the usual tablets they receive. You ask the patient to read the imprint code on the tablets, and you realize that they were dispensed metolazone instead of metoprolol. You believe that a technician manually bypassed the barcode scan, and you missed this error during the verification step.

You ask the patient if they can immediately bring the medication vial back to the pharmacy. The patient agrees and states that they have not yet taken any of the medication.

About 20 minutes later, the patient arrives at your pharmacy. Please counsel the patient on the medication dispensing error that occurred.

Additional information provided to activity facilitator ONLY

You will begin the encounter by saying, “Hi, I spoke with you on the phone. I think I was given the wrong medication.” Allow the intern pharmacist to counsel you on the error that occurred. Because every student’s approach to this consultation will be unique, you will need to improvise your responses.

At some point during the encounter, ask the following question:

  • “I know we are all human and make mistakes, but it seems that something like this just should not happen. How does this occur?”

    • Example of appropriate response: “First, I sincerely apologize that this occurred. You are right that this should not happen, and we take it very seriously. We will complete a full review of our process to find out how this happened and ensure it does not happen again.” (Criteria 1 and 5 on assessment rubric)

After the intern pharmacist addresses the question above, you should act understanding, pleasant, and thankful for the remainder of the encounter.

After the encounter concludes, review the assessment rubric with the student.

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