DFI and Corrective Action

March 2016

Dear Professional Colleague,

A Drug Furnishing Incident (DFI) occurs with such errors as, but not limited to, wrong drug, wrong strength, wrong quantity, wrong directions, or wrong patient. DFIs occur when a medication has left the control of the pharmacy into the control of the patient or their agent – even if the medication has not yet left the pharmacy.

There are 5 Levels of Corrective Action.
Level 1 - Problem Solving (Initial Reminder)
Level 2 - Problem Solving (Individual Action Plan)
Level 3 - Discipline (Corrective Action Plan)
Level 4 - Discipline (Day of Decision: Last-Chance Agreement)
Level 5 – Discipline (Termination)

Please know that some KP SCAL outpatient pharmacy managers have taken a very aggressive stance on the DFI policy where a single instance has resulted in a Level 4 Corrective Action – meaning that a similar mistake in the handling of a DFI within the next 12 months could result in a Level 5 termination.

Ask your manager for a hard copy of the DFI Form and DFI Quality Assurance Program and become familiar with its provisions.

Most of the recent issues resulting in Corrective Action involve how a DFI was documented and processed.

The following issues are the most common examples from recent Corrective Action meetings:

Not reporting that a DFI occurred, by informing management or filling out a DFI form, for ANY instance of wrong drug, wrong strength, wrong quantity, wrong directions, or wrong patient
Not checking if the patient took ANY medication
Not contacting the provider if the patient took ANY medication
Not quarantining 100% of the returned medication
Not teching through a new label when providing the patient with correct medication or missing quantity. A label reprint is NOT sufficient.

Our Union strongly advises all pharmacists to work in a manner that guards patient safety, the purity of the drug supply, and your ability to provide high quality patient care. Do not sacrifice safety for speed.

In Unity,
Sheri Gotanda

Sheri Gotanda, PharmD | Staff Representative – UPSC
909-599-8622 (o) | 909-451-1644 (c)
sheri.gotanda@unacuhcp.org