Dispensing Errors

Article from www.dora.state.co.us/pharmacy

Pharmacy board staff recently conducted research on complaints received by the Board for Fiscal Year 2010. Not surprisingly, as previous years have shown, dispensing errors account for the majority of complaints. Complaints categorized as dispensing errors encompass a broad spectrum—from order entry issues, wrong drug, counting errors, or failure to provide a medication guide.

These errors were then further divided into the part of the dispensing process where the error occurred. Did the error occur at the point of initial interpretation or at the point of placing the medication into the container and labeling it properly? The results indicated that approximately 50% of the dispensing errors occurred at the point of initial interpretation. Errors included not recognizing drug allergies, drug interactions, order interpretation, or failing to catch inappropriate medications or dosages.

Pharmacists need to have a heightened awareness regarding dispensing errors. If you are supervising technicians who conduct order entry, use extra vigilance in reviewing their work. If allergies, interactions, drug usage, and patient profile alerts must be overridden, do not allow others to use your override codes. Remember, you as the pharmacist, are accountable for the accuracy of those you supervise. If something on the order doesn’t make sense, contact the prescriber for clarification.

Some suggestions for minimizing the possibility of errors are listed below. They may or may not be pertinent for your practice setting and should not be construed as the only factors that should be considered. Each pharmacy should assess its own practices and determine the best methods to avoid dispensing errors. However, all pharmacists need to be vigilant and take steps to prevent errors.

1. Lock up or sequester drugs that could cause disastrous errors;
2. Develop and implement meticulous procedures for drug storage;
3. Reduce distractions, design a safe dispensing environment, and maintain optimum work flow;
4. Use reminders such as labels and computer notes to prevent mix-ups between "look-alike" and "sound-alike" drug names;
5. Keep the original prescription order, label, and medication container together throughout the dispensing process;
6. Perform a final check on the contents of prescription containers;
7. Compare the contents of the medication container with the information on the prescription label;
8. Enter the manufacturer's identification code in the computer and on the prescription label;
9. Perform a final check on the prescription label. When possible, use automation, such as bar coding;
10. Provide patient counseling;
11. Make sure drug references in the pharmacy are current;
12. At minimum, double check all calculations;
13. Have all prescriptions double checked by another person, if possible
14. The computer merging of files (drug or patient) should always be supervised.
15. Review the Institute for Safe Medication Practices website at ISMP.org regularly for suggestions on preventing errors and for information on drug names that are commonly confused.
16. Review FDA.gov on a regular basis to find out which drugs need medication guides to be distributed to the patient. Enact procedures in the pharmacy in which you work to ensure that medication guides are attached to every prescription for which they’re required.

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