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Mix-up causes the wrong patient to receive STI prescription

09 February 2021 | Dr Rosa Canalese, MBBS, Dip Paed, FRACGP, Senior Medical Adviser, Claims Manager, Avant and Georgie Haysom, BSc LLB (Hons), LLM (Bioethics), GAICD, Head of Advocacy, Avant

A GP’s mistake reminds doctors how important it is to check a patient’s identity before prescribing treatment.

In this scenario*, a doctor incorrectly informed a patient, Miss B, who had been recalled for follow-up, that she was diagnosed with chlamydia.

The doctor gave her a prescription for an oral antibiotic, informed her that the Public Health Unit would be advised of the result and discussed notifying previous sexual partners with her.

It wasn’t until Miss B arrived at the chemist and presented the prescription to the pharmacist that the mix-up was identified. The pharmacist realised the script was intended for someone else after checking Miss B’s identity against her Medicare card.

The mix-up

Miss B and the other patient were of similar age and ethnicity. The doctor was not Miss B’s regular GP and had never treated her, nor the other patient prior to this incident.

When the doctor called out the name of the other patient, Miss B misheard him and followed him into the consulting room.

During the entire consultation the doctor believed Miss B was the other patient diagnosed with chlamydia. He did not check the patient’s identity and as he explained the test results, Miss B, while not recalling that she had undergone STI testing, just assumed it was part of her recent cervical screening test.

Identification of error

Miss B returned to the medical practice the following day to inform the doctor of the mix up. The doctor claimed Miss B had answered to the name of the other patient and did not assume responsibility for giving her the incorrect prescription. As Miss B had not taken the antibiotic, no harm had been done in his view.

Miss B claimed he merely brushed off the error and didn’t apologise for his actions. The doctor did not document the error in Miss B’s medical notes.

This scenario also raises the additional issue of the breach of privacy for the patient for whom the prescription was written.

Patient files complaint

Miss B filed a complaint about the doctor’s care to the state’s complaints body which led to an investigation. The doctor was found to have failed to:

  • establish Miss B’s identity before consulting with her
  • obtain an accurate medical history
  • check the accuracy of the prescription information
  • document the identity and medication error in Miss B’s clinical notes. 

Key lessons

This case highlights that doctors should only prescribe medicines or treatment when they have adequately assessed the patient’s condition and are satisfied the treatment is in their best interests.  

According to the Medical Board of Australia’s Code of Conduct, effective communication is core to the doctor-patient relationship and involves listening to patients and encouraging them to tell you about their condition, including any medications they have been prescribed. 

Doctors can also minimise medication errors by following the advice below:    

  • Ensure you establish the identity of any patient you have not treated before by asking them to repeat their full name and date of birth.  
  • Obtain the patient’s medical history and communicate any concerns about current or past prescriptions with them.
  • Communicate clearly and listen carefully to any patient concerns which may raise important ‘red flags.’
  • If an error does occur, document the error in the patient’s medical records. In this case, the documentation should include both the identity error and the incorrect administration of the antibiotic.
  • This doctor discussed the error but didn’t apologise. In Australia, the open disclosure standard says you should say sorry. This may have prevented the complaint. 
  • Put in place practice systems to review errors and implement steps to reduce further risk of error.

A variety of factors can influence a patient to lodge a complaint or compensation claim against a doctor. Our analysis on factors underlying diagnostic error claims supports literature which found patients who have issues with their doctor’s manner or communication style, are more likely to make a formal complaint1,2.

Useful resources

For more information about documentation and medical records, see our factsheet and eLearning course. We also have more information in the Avant Learning Centre on prescribing and open disclosure.

If you receive a claim or complaint, contact us for medico-legal advice via email at nca@avant.org.au or 1800 128 268, available 24/7 in emergencies.

*This scenario is based on an actual experience of one of Avant’s GP medical advisers. Certain information has been de-identified to preserve privacy and confidentiality. This publication is not comprehensive and does not constitute legal or medical advice. You should seek legal or other professional advice before relying on any content, and practice proper clinical decision making with regard to the individual circumstances. Avant is not responsible to you or anyone else for any loss suffered in connection with the use of this information. Information is only current at the date initially published. © Avant Mutual Group Limited 2021.


  1. Oyebode F. Clinical Errors and Medical Negligence. Med Princ Pract. 2013 Jun;22(4):323-333.
  2. Roter D. The Patient-Physician Relationship and its Implications for Malpractice Litigation. J. Health Care L. & Pol'y. 2006; 9(2);304-314.


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