Report of deviation – Critical incident, therefore my low rating as a professional
Date: 2025-09-04
Location: Apoteket Illern, Surahammar
Incident category: Serious deviation – risk of patient harm, incorrect medication handling, breach of confidentiality, lack of responsibility.
Incident description
I visited Apoteket Illern in Surahammar to collect my ApoDos. The pharmacy staff handed out two dose rolls and stated that both were mine. I questioned this as the amount of medication did not match.
Upon inspection, I discovered that one of the dose rolls belonged to another patient – a woman born in 1943 named Margareta. I could clearly read her full name, social security number and medication list. This is a direct violation of confidentiality and the pharmacy's responsibility to protect patient information.
When I pointed out that the dose roll was not mine, the pharmacist first insisted that it belonged to me. I explained that I am a nurse and can read social security numbers. “It doesn’t matter that you are a nurse,” said the foreign pharmacist. Despite this, the pharmacist tried to hand out the incorrect dose roll once more.
Addendum – handling after the incident
When I asked to speak to the pharmacy manager, I was denied contact. The staff also refused to call the manager.
I asked to see the deviation that must be documented by law, but the pharmacy refused to let me see or read it.
The pharmacist responsible for the situation refused to take responsibility for the error.
Because of this, I immediately reported the error to IVO the same day, as I felt that the pharmacy did not take the incident seriously and did not take the necessary measures.
Risk to patient safety
If I had started medication from the wrong roll, I would have ingested 10 new medications in high doses (including several at 100 mg), which could have caused serious harm to health or death.
The patient Margareta, 82 years old, had also been left without her life-saving medications, which had exposed her to an acute risk of deteriorating health or death.
Assessment
This is a critical deviation with the following serious shortcomings:
Incorrect dispensing of medication (risk of life-threatening patient harm).
Confidentiality breach – the patient’s personal data and medication list were exposed.
Lack of responsibility – the staff refused to take responsibility for the error.
Lack of transparency – the customer was denied contact with the manager and insight into the deviation.
Risk of repetition – indicates a system error in the procedures for ApoDos dispensing.
Suggested action
Immediate reporting to IVO (The Swedish Health and Care Inspectorate) – already carried out by me as a patient.
Internal investigation according to the pharmacy's deviation management, including management level.
Review and reinforcement of procedures for dispensing ApoDos for foreign pharmacists who did not follow procedures at the time of the deviation
Immediate training of staff in patient safety, confidentiality and treatment.
Ensure that the affected patient (Margareta) receives correct information and access to her medications without delay.
Summary
The incident is a serious deviation where the wrong dose roll risked being given out and could have led to life-threatening consequences for two patients. In addition, the confidentiality of patient information has been breached. When this was pointed out, the staff refused to let me speak to the responsible manager, refused to let me see the deviation and did not take responsibility for the error.
The pharmacy's actions violate fundamental requirements for patient safety, confidentiality and accountability. The incident requires immediate action and supervision.
Sincerely
Caroline Stenholm registered nurse
34
