Transcript Misinterpreted Physician’s Prescriptions

Preventing
Dispensing Errors
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
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.
Most Prevalent Dispensing Errors
• Dispensing incorrect medication, dosage
strength, or dosage form
• Dosage miscalculations
• Failure to identify drug interactions or
contraindications
Types of Dispensing Errors
• Commission versus omission
• Mistake versus slip
• Potential versus actual
Errors of Omission
• Failure to counsel the patient
• Failure to screen for interactions and
contraindications
Errors of Commission
• Miscalculation of a dose
• Dispensing the incorrect medication,
dosage strength, or dosage form
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
Dispensing Errors:
Common Causes
• Work environment
– Workload
– Distractions
– Work area
• Use of outdated or incorrect references
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
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
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
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Poor ergonomics
Lighting
Heat, humidity
Noise (TV, radio)
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
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 errorprone products
• Use of exaggerated, unconventional type
fonts to enhance reading of drug names
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
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
Poor Communication Dynamics
From a Published Reference
Ambiguity in Written Orders
Computerized Prescribing Errors
• Computerized prescriber order entry
(CPOE) improves communication and
reduces some types of errors
• However, this technology may have its
own pitfalls:
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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
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
Optimal Capabilities of
Pharmacy Computer Software to
Prevent Dispensing Errors
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Dose limits
Allergic reactions
Cross-allergies
Duplication of drug ingredients
Drug interactions
Contraindicated drugs or drugs that need
dosage modifications
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
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
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
Inpatient Oral Medication Label
Format: Minimum Content
Properly Labeled Syringe
Outpatient Label Content
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Patient name
Medication name
Dosage strength
Dosage form
Quantity
Directions for use
Number of refills
Prescriber name
Purpose of medication
Example of a Safer
Prescription Container
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
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
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
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
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
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.
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!
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
10 Steps to Maximize
Dispensing Accuracy
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 workflow
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
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
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.