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
The top three dispensing errors include (1) dispensing an incorrect medication, dosage strength, or dosage form, (2) dosage miscalculations, and (3) failure to identify drug interactions or contraindications.1
The first step to preventing dispensing errors is to identify the causes. Then, new policies and procedures can be instituted and the staff can be educated. 1

5. Types of Dispensing Errors
Commission versus omission
Mistake versus slip
Potential versus actual
The are various ways dispensing errors can be classified:
Commission/Omission- Dispensing the wrong drug or dose would be an error of commission. Whereas, failure to counsel a patient or screen for drug interactions would be considered an error of omission. 1
Mechanical/Judgmental- Mechanical errors are those which occur during the preparation and processing of a prescription. Judgmental errors, on the other hand, are those involving patient counseling, screening, or monitoring. 1
Slip/Mistake- Slips are often caused by poor design or distraction. An error related to reliance on automatic behavior, after a distraction has occurred or poor system design, would be considered a slip. An error due to conscious deliberation, perhaps because of a lack of knowledge, would be considered a mistake. For example, a mistake may occur if a pharmacist does not know that there are 2 strengths of Prozac® available. 1, 3
Potential/Actual- Potential errors are those which are detected and corrected prior to the administration of the medication. Whereas, actual errors are those which actually reach the patient. 1

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 Slip
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
The most common causes of dispensing errors are related to either the work environment or the use of outdated or incorrect references. Factors in the work environment that may contribute to dispensing errors include work load, distractions, and the design of the work area. 1

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
Solutions to work overload would include ensuring adequate staffing levels and eliminating time limits on dispensing. One state pharmacy association has issued an Employee Model Contract. This contract states that no pharmacist should routinely dispense more than an average of 15 prescriptions per hour. Additionally, pharmacists should be required to take rest breaks every 2-3 hours and 30 minute meal breaks. 1
Although, profession-wide acceptance of these recommendations is not likely, employers have been disciplined by state boards of pharmacy and the courts of law when unreasonable workloads have led to dispensing errors. 1

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
A well-designed drug storage area may also reduce dispensing errors. Since crowded medications are more likely to be interchanged or returned to the wrong place, adequate space should be allotted for each medication and each strength.4 All prescription bottles should be stored with the label facing forward. If only the storage label is used for identification, medications in similar packaging can be mistaken for one another. Therefore, shelves, bins, cabinets, or drawers with external storage labels should not be used for storage.5
Medication storage should be separated according to route of administration (i.e., oral, injectable, inhaled, topical, otic, ophthalmic, and rectal). Some pharmacies even separate oral liquids from other oral medications. Auxiliary labels indicating the route of administration should be used to differentiate medications upon dispensing.1
“High-alert” medications (i.e., warfarin, injectable potassium chloride, lidocaine, heparin, and controlled substances) should be specially marked and placed in an isolated or locked area. If this is not possible, auxiliary labels should be used to draw attention to the product and warn the pharmacist to use additional caution.1, 8
Ideally, frequently confused drug pairs (i.e., thiamine 100 mg and thioridiazine 100 mg) should be separated.8 Although lists of frequently confused drug-name pairs are available [ their utility is limited because it is impossible for pharmacists to memorize them. Computer warnings, however, can prevent mix-ups between products with similar names and strengths. Many computer systems have a “clinical flag” or “formulary note” screen that can show important information. This feature can alert the pharmacist entering the order when a look-alike or sound-alike potential is present. For example, when Norvasc® is entered into the computer, a formulary note screen can appear to alert the pharmacist that it often looks like Navane®. This should then prompt the pharmacist to verify the order.1

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
Top image: Amaryl 2 mg (top line) was misread as 12 mg.
Bottom image: Tegretol 300 mg was misread as Tegretol 1300 mg

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
Computer order entry involves the selection of the correct medication, dosage strength, dosage form, quantity, directions for use, number of refills, and prescriber name. All of these parameters should be included on the label. If possible, the purpose of the medication should be printed on the dispensing label. Including the purpose on the label provides the patient with an additional means to verify and distinguish among their prescriptions. 1

28. Prescription Container
Example of a Safer
Prescription Container
Example of Target’s ClearRx prescription vial and label.

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
Suggest removing this bullet - yes I know its in the book but even ISMP can come up with a singer once an a while - this sounds like we are asking a pharmacist first to read “amoxacillin” and then to reread the drug name backwards – “nillicaxoma” that’s like trying to get Mr. Mxyzptlk to say his name backwards (try googleing it). The technique of reading word sequences in reverse order (not reading words backwards) helps editors to identify spelling errors.

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
Illegible handwriting, nonstandard abbreviations, or incomplete orders must be clarified with the prescriber. Any clarification should be documented in writing. 1
The pharmacist should then analyze the patient’s profile. This will allow the pharmacist to review any potential drug interactions and allergies. The pharmacist can then verify the appropriateness of the medication and its dosage. Computer alerts must also be considered at this time. An additional precautionary task is to highlight any unusual dosage form or strength that is prescribed. 1

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.