ABSTRACT
One morning, Mrs. Tina Green, a patient who regularly collects medications from Community Pharmacy Limited, arrived in the pharmacy and wanted to speak to the manager, Dianne Watts. Dianne invited Mrs. Green to the consultation room. She was very agitated and produced a pack of Xalacom® eye drops from her handbag. It had been dispensed the previous day. She complained that she had been given Xalacom instead of Xalatan®. Fortunately, she said she detected the mistake when she was about to use the drops. Dianne went to the pharmacy and collected the dispensed script. The prescription had been for Xalatan, and the pharmacist and the dispenser had dispensed Xalacom in error. Dianne apologized for the
error and corrected the mistake immediately. Mrs. Green accepted the apology with the assurance that it would not happen again. Dianne then called Max and the dispenser to her room and sternly warned them that it should not have happened and their performance was not acceptable. Dianne was not interested in finding out how it occurred or how it could be prevented in the future. Max and the dispenser left the room disheartened.
