Preventing Dispensing Errors

1. Preventing Dispensing Errors

2. Learning Objectives • Describe dispensing errors related to the work environment • Discuss the roles of computerization in the prevention of dispensing errors • Explain the steps involved for ensuring dispensing accuracy

3. Dispensing Errors: The Numbers • 98.3% accuracy in dispensing medications • Therefore, 1.7% inaccuracy rate • Over 3 billion medications dispensed per year • 4 errors per day per 250 prescriptions filled • Over 51 million dispensing errors per year • Flynn E, et al. J Am Pharm Assoc. 2003;43:191–200.

4. Most Prevalent Dispensing Errors • Dispensing incorrect medication, dosage strength, or dosage form • Dosage miscalculations • Failure to identify drug interactions or contraindications

5. Types of Dispensing Errors • Commission versus omission • Mistake versus slip • Potential versus actual

6. Errors of Omission • Failure to counsel the patient • Failure to screen for interactions and contraindications

7. Errors of Commission • Miscalculation of a dose • Dispensing the incorrect medication, dosage strength, or dosage form

8. Mistakes and Slips • Mistake • Do things intentionally but actions are incorrect because of a knowledge or judgment deficit • Behavior in problem solving mode • Example: dose prescribed that exceeds maximum safe limit • Slip • Do things unintentionally incorrect because of an attention deficit • Behavior in automatic mode • Example: dispense chlorpromazine when prescription was clearly written for chlorpropamide

9. Dispensing Errors: Common Causes • Work environment • Workload • Distractions • Work area • Use of outdated or incorrect references

10. Dispensing Errors: Improving Workload • Ensure adequate staffing levels • Eliminate dispensing time limits (quotas) • Examples of limiting workload • Dispense ≤150 prescriptions per pharmacist per day • Require rest breaks every 2–3 hours • Brief warm-up period before restarting work tasks • Require 30-minute meal breaks

11. Dispensing Errors: Combating Distractions • Phones • Fax machines, auto refill, voice mail, priority processing, trained support personnel • Prohibit distractions during critical prescription-filling functions • Centralized filling operations • Train support personnel to answer the telephone

12. Dispensing Errors in the Work Area • Clutter (return used containers immediately) – Ensure adequate space – Store products with label facing forward – Choose high-use items on the basis of safety as well as convenience, use original containers – Telephone placement • Poor ergonomics • Lighting • Heat, humidity • Noise (TV, radio)

13. Dispensing Errors in the Work Area • Labels on bins and shelves – Failure mode: bin label may decrease chance that the actual product label will be checked when selected from bin; using bar codes will decrease chance of error • Separate by route of administration (external/internal/injectable, etc.) • Use auxiliary labels for externals – Amoxicillin oral suspension for ear infection thought by parents to be drops administered in child’s ear • Review published safety alerts for look-alike/ sound-alike drugs and frequent dispensing errors

14. Cognitive and Social Factors • Use of high-intensity task lights and magnification • Use of a device to hold prescriptions/orders at eye level • Posting alerts in strategic locations with error-prone products • Use of exaggerated, unconventional type fonts to enhance reading of drug names

15. Well-Designed Drug Storage • Adequate space • Label facing forward • Agents for external use should never be stored with oral medications • Separate by route of administration • Mark and/or isolate high-alert drugs • Separate sound-alike/look-alike drugs

16. Errors Related to Information About the Drug or Patient • Misleading or erroneous references • Ambiguity in handwritten and typed documents • Computerized prescribing • Wrong patient errors • Errors in dosage

17. Poor Communication Dynamics From a Published Reference

18. Ambiguity in Written Orders

19. Computerized Prescribing Errors • Computerized prescriber order entry (CPOE) improves communication and reduces some types of errors • However, this technology may have its own pitfalls: • Lower case L may look like the numeral 1 • Letter O may look like the numeral 0 (zero) • Letter Z and the numeral 2 may be misread • Wrong patient or wrong drug chosen from list

20. Computerized Alerts • Computer systems can be configured to flash maximum dose alerts and other safety alerts • Upgrades are necessary and usually available from software vendors

21. Optimal Capabilities of Pharmacy Computer Software to Prevent Dispensing Errors • Dose limits • Allergic reactions • Cross-allergies • Duplication of drug ingredients • Drug interactions • Contraindicated drugs or drugs that need dosage modifications

22. Errors in Dosage • Mathematical errors and decimal point misplacement are common causes of errors, especially in conversions between micrograms and milligrams • Oral liquid medications can be dispensed improperly because of misunderstandings with reading and labeling of oral syringes or use of such devices by parents of pediatric patients

23. Dispensing Errors Caused by Poor Labeling • Pharmacy computer-generated labeling and production of medication administration records should be optimized • Nonessential information should be excluded from labels and reports • Samples may be poorly labeled

24. Syringe and Admixture Labels • Standardization of the way labels are placed on syringes can reduce errors • Use of “For Oral Use Only” labels on oral syringes • Placement of labels on IV bags • Warning labels for special parenterals • Vinca alkaloids, other antineoplastics • Medications with specific infusion rates

25. Inpatient Oral Medication Label Format: Minimum Content

26. Properly Labeled Syringe

27. Outpatient Label Content • Patient name • Medication name • Dosage strength • Dosage form • Quantity • Directions for use • Number of refills • Prescriber name • Purpose of medication

28. Example of a Safer Prescription Container

29. Errors Related to Dispensing Methods • 24-hour pharmacy service reduces errors • Unit-dose dispensing should be utilized whenever feasible • Requiring multiple tablets to be taken for one dose may result in an underdose

30. Manual Redundancies • Independent double checks before dispensing • Original prescription order, label, and medication container should be kept together throughout the dispensing process • Pharmacist must check all of technician’s work

31. Manual Redundancies (continued) • Self-checking by a lone practitioner may be safer if: • Switching hands when rereading the label • Delay of self-checking • Recalculating using a different process

32. Manual Redundancies (continued) • Compounded products can be checked before dispensing utilizing new qualitative and quantitative analysis techniques • Use of standardized concentrations of frequently used formulations reduces errors

33. Dispensing Errors Caused by Poor Patient Education • Failure to adequately educate patients • Lack of pharmacist involvement in direct patient education • Failure to provide patients with understandable written instructions • Lack of involving patients in check systems • Not listening to patients when therapy is questioned or concerns are expressed

34. Counseling Patients • Up to 83% of dispensing errors can be discovered during patient counseling and corrected before the patient leaves the pharmacy Ukens C. Drug Topics. March 13, 1997:100–11.

35. Good Patient Education • Inform patients of drug names, purpose, dose, side effects, and management methods • Suggest readings for patient • Inform patient about right to ask questions and expect answers • Listen to what patient is saying and provide follow-up!

36. Assessing Prescriptions • Clarify illegible handwriting, nonstandard abbreviations, or incomplete information • Analyze patient’s profile • Review drug interactions and allergies • Verify appropriateness of medication and dosage • Consider computer alerts • Highlight unusual dosage form or strength

37. 10 Steps to Maximize Dispensing Accuracy • Lock up or sequester drugs that could cause disastrous errors • Develop and implement meticulous procedures for drug storage • Reduce distractions, design a safe dispensing environment, and maintain optimum workflow • Use reminders such as labels and computer notes to prevent mix-ups between look-alike and sound-alike drug names • Keep the original prescription order, label, and medication container together throughout the dispensing process

38. 10 Steps to Maximize Dispensing Accuracy 6. Compare the contents of the medication container with the information on the prescription 7. Enter the drug’s identification code (e.g., national drug code [NDC] number) into the computer and on the prescription label 8. Perform a final check on the prescription, the prescription label, and manufacturer’s container; when possible, use automation (e.g., bar coding) 9. Perform a final check on the contents of prescription containers 10. Provide patient counseling

39. References Flynn E, Barker KN, Carnahan BJ. National observational study of prescription dispensing accuracy and safety in 50 pharmacies. J Am Pharm Assoc. 2003;43:191–200. Ukens C. Deadly dispensing: an exclusive survey of Rx errors by pharmacists. Drug Topics. March 13, 1997:100–11.