When it comes to drinking tea, both my husband and I are a bit of a snob. We are very particular about our drinking tea habits. We discuss about what tea we like, the aroma we prefer, the temperature of the water we demand and how long we sip our tea bag / leaves to make the perfect cup of tea. We sometimes even argue over which mug we should use. So when we decided to indulge ourselves with two cups of Chai tea at the local Starbucks, what could go wrong?  We couldn’t expect the experience to be seamless or  just plain satisfactory.

I told the barista I would like two Venti (Extra Large) Chai tea.  So he punched in few keys in the cash register and I paid for the orders. Few minutes later, two Venti Chai Latte showed up in my face. I told a different barista we only wanted the Chai tea, not Chai Latte. So she spoke with the other barista and apologized. Then she proceeded to give me two cups of Chai tea, except she put them in two Grande (large) cups instead of the Venti (Extra Large) size that I had requested initially. I looked at her again and said we liked our tea in Venti size cups.  She switched to the Venti size cups but didn’t top up the cups with more hot water. So I had to ask again if she could fill it up with water to the top. She proceeded to do so at the sink. I almost flipped out because I thought she was going to top it up with cold water. It turned out the water was hot coming from the tap,  at least this was what she told me.

Now imagine it was a medication error involving an order for risperidone 1mg po daily for 30 tablets which the patient had requested in a easy open vial.  The order was processed as risperidone M-tab 1mg po for 30 tablets which was dispensed in individually packaged unit dose.  Risperidone M-tab is a fast dissolving formulation which is not the same as risperidone. When the error was detected  – that it was the wrong drug – the technician processed the order with the correct medication, except it was not dispensed in an easy open vial.  The patient was disappointed that her original request was ignored.  The technician went to print a new label, transferred the medication in an easy open vial and had the medication verified again before releasing it to the patient.

In both examples, some may say it was no big deal.  Both the customer and the patient eventually got what they wanted.  But I would argue it was through a painstaking journey, an experience that may leave both the customer and patient feeling upset or unhappy that their personal requests were not taken seriously.

When conducting a root cause analysis of medication incidents, we often look at various factors such as:

  • Standard Operating Procedures
  • Education and Training
  • Communication
  • Medication Safety
  • Patient Engagement

In these two examples, many of these factors are applicable.  For instance, the current standard operating procedures might not involve a formal step to consider special requests from the customers / patients. Hence, there was no formal process to follow to ensure these requests were met. Staff members and employees might not have received the necessary training to listen to the customers and patients and to pay attention to their special requests. Communication is definitely a factor here.  The barista assumed I wanted Chai Latte when I specifically said Chai tea.  If a clarification was sought at this step, then the entire misunderstanding could have been avoided. The pharmacy technician might not be aware of the two formulations of risperidone.  Also if the patient’s profile was reviewed, it would have prompted the pharmacy technician to realize the patient was previously on the risperidone, not risperidone M-tab.  This should have prompted her to seek out clarification with the patient.

But the main factor that should be explored is patient engagement. I felt that when the barista realized an error was made, there was a wall that went up.  She acted like she just wanted me to disappear quickly.  In the case of the risperidone, it mattered a lot to the patient to have the medication dispensed in an easy open vial and when this request was ignored, it sent a strong message that she was not taken seriously. It really didn’t matter an error was made, but what was important was the attitude around dealing with the error, being open and honest and a genuine attempt to resolve the error quickly.

In an era where patient satisfaction and client engagement are important for business retention and improved patient outcome, we need to pay more attention how to incorporate steps and processes to ensure these special requests are taken seriously and have clear procedures to acknowledge and incorporate them.  Otherwise, the customer or patient will leave with a bad experience, feeling dissatisfied and disengaged and….. eventually they will decide to leave forever, for good.

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