Introduction
There is agreement that since neither dispensing discrepancies (a potential error which does not reach the patient) or medication errors (in which the patient actually receives the erroneous prescription) can be eliminated completely, an open process of evaluation and discussion is required each time a mistake occurs. This will result in practice changes to prevent future errors. Procedures for preventing and handling errors are addressed in this unit.
According to graduating students and leading edge practitioners, environments in which medication errors are more likely to occur tend to be characterized by:
- disorganized work flow
- fatigued staff
- frequent interruptions and distractions
- poor physician handwriting
- emphasis on volume over service quality
- stress
- ineffective communication with patients
- improper technician training
- a pattern of inadequate staffing.
As pharmacists devote more time to counselling and providing cognitive services in order to achieve desired health outcomes, the need to implement procedures and policies to prevent errors should not be forgotten. Leading edge practitioners commented that all pharmacy practices are prone to medication error, which is due, after all, to the human element inherent in pharmacy practice (i.e. we're people!). It was felt that consumers accept the fact that pharmacists are human and errors will be made, but that the way an error is handled is critical.
Standards of Practice
Practice Unit #8 supports in general Standard #6 of NAPRA's "Model Standards of Practice for Canadian Pharmacists""The pharmacist applies knowledge, principles and skills of management as they pertain to the site of pharmacy practice, with the goal of optimizing patient care and inter-professional relations."
Specifically, this unit supports Operational Sub-Component #6.1.3 of the Standards.
Common suggestions for practice changes to decrease the risk of errors
Human Resources
- More technical work should be done by technicians
- Clear checking procedures for technicians and pharmacists
- Maximum of two technicians per pharmacist
- Well defined roles and job descriptions for all functions in the dispensary
- Technician certification or adequate technician training
- Work in teams
- Staff meetings to address annual and regular reviews and discussions after errors
Dispensing Procedures
- Electronic DIN scan
- Ensure accountability through identifying staff involved at each step in the process
- Do not hesitate to question a prescription if it is unclear
- Be clear about what is wanted/needed by the patient, ensure that checks occur in every step of the dispensing process
- Always take the time necessary to do all of the checks - don't be rushed by a "low time" parking meter
- Be aware of other potential sources of error such as look-alike, sound alike drug names and products, drugs for which a reasonable dose may vary by a factor of 10 (e.g. Prednisone 5 mg vs. 50 mg.) drugs with a high potential for negative outcomes or a large variation in prescribed dosages (e.g.warfarin)
- Provide thorough patient counselling beginning by asking the patient what their physician told them the medication was for
- Show the patient the tablets or capsules to ensure they are receiving the medication they expect to receive
Policies
- Institute a policy for error evaluation and subsequent practice improvement
- Insist all sales reps make appointments, don't allow them to "drop in because the doctors' offices are closed"
Controversy exists around some practices. While many pharmacists institute policies that ensure a second check by a different person ("no-one checks their own work"), there is an opposing view that people may be less careful about their work when they know that someone else is going to check it anyway. There also appears to be no consensus on the ideal staffing level based on numbers of prescriptions filled. Time taken to fill each prescription and numbers of prescriptions filled per hour varies by practice and within each practice by time of day, week, month etc. It appears that an accepted ratio of pharmacists: technicians is 1:1+1, but there is no documentation in the literature to support this, nor is it required by provincial licensing bodies.
Dispensary re-design to decrease the risk of errors
- Minimize interruptions, e.g. headsets to answer phones, specific staff assigned to phones
- No postal outlet; no cash register
- Keep traffic flow in the dispensary at a minimum
- Adequate space to perform each function
- Non dispensing functions, such as stock control, filing etc., should be separated from the prescription filling area
- Ensure adequate storage space for supplies, books, etc. to minimize clutter
- UPC computerized scanner to verify product entered - DIN check
- Picture of medication on computer screen for technician and pharmacist
- Large work counter for technicians and a system in place for checking
- Separate pharmacist service counter, where pharmacists discuss therapy with patients, from the rest of the dispensing process
- A dedicated phone line for physician/pharmacist communication
- Work flow should facilitate pharmacist review with profile and patient without interruptions
- Electronic exchange of information to enhance prescription legibility, provide patient history, diagnosis, etc.
- Shadow-box displaying tablets or capsules used in automated counting cells
A more complete discussion on all aspects of redesign is found in the Unit on Facilities, Equipment, Supplies; Workflow and Facility Redesign.
This unit contains tools and resources from the Institute for Safe Medication Practices, the literature and from licensing bodies and associations. Pharmacists must commit to learning from errors that have occurred, both within their own practices and from other examples. Systems and policies that minimize risk and prevent errors are needed. As well, advice is given about handling medication errors.
Canadian Error Reporting Systems
College of Pharmacists of British Columbia Bulletin: "What went wrong?"
This regular feature publishes medication incidents received and investigated by the College's Inquiry Committee. The intent is to assist pharmacists to reflect on their own practices and take steps to prevent errors, by categorizing medication errors: e.g. look alike sound alike, expired drugs dispensed, lack of privacy, wrong drug dispensed, and failure to review patient profile.
The Bulletin is distributed without charge to members of the College.
Ontario College of Pharmacists
Pharmacy Connection publishes disciplinary proceedings, which are also a valuable source of information about medication errors. This journal is issued free of charge to members of the College.
Preventing errors
"Causes and Prevention of Medication Errors" - Institute for Safe Medication Practices
Although this resource is U.S. based, the advice and practical strategies apply to pharmacy practice in Canada. This error reporting program can be reached 24 hours/day at 1-800-23-ERROR. A comprehensive 1997 document, it sets out what causes errors in terms of problems:
- common to all health professionals,
- most often but not exclusively associated with prescribers,
- most often but not exclusively associated with nursing,
- most often associated with pharmacists, and
- associated with pharmaceutical manufacturers and regulatory agencies
The document then recommends risk management strategies.
One section deals with human errors in medicine - "Failure Mode and Effects Analysis" (FMEA) and provides tools for assessing the potential for error, such as:
· a high hazard medications list
· a framework for improvement
· a special section on preventing cancer chemotherapy errors,
· a form for the USP Medication Errors Reporting Program (in cooperation with the Institute for Safe Medication Practices )
Ontario Pharmacists' Association
"Quality Assurance in Pharmacy Services - Confronting Medication Errors" was developed to make pharmacists aware of the incidence, causes and handling of medication errors in practice. It includes consideration of system/work flow factors, communication and documentation. It is presented in a 2-hour workshop that includes slide presentation and discussion, small group discussion of a case study and role-playing. It was developed in collaboration with Abbott Laboratories and has been presented at various locations across Ontario.
Saskatchewan Pharmacists Association
" Ensuring Dispensing Accuracy - some simple suggestions" was published by the Saskatchewan Pharmacists Association, and lists the following 13 suggestions.
1. Lock up or sequester drugs with a high potential for causing errors
2. Careful drug storage
3. Reduce distractions
4. Design a safe dispensing environment
5. Be aware of look alike sound alike names
6. Be aware of look alike labels
7. Be aware of poor abbreviations
8. Develop thorough checking procedures
9. Adequate computer systems
10. Patient Counseling
11. Physician handwriting
12. Stress and unreasonable workloads
13. Have a comfortable patient waiting area
American Pharmacists' Association
APhA publishes "Principles of Good Pharmacy Practice: Drug Error Management". This document is available from APhA and includes the following information:
Techniques described by practitioners
Techniques used by surveyed practitioners to decrease the risk of errors include:
- Separate all components of each prescription being filled into bins throughout the entire dispensing process
- Fill from the original prescription, not the label printed when the prescription is entered into the computer system
- Triple check:
1. The original prescription to the bottle;
2. The label to the original prescription and bottle, including the DIN;
3. As pharmacist hands the prescription to the patient, comparing the original prescription to the label and to the drug.
Handling errors
Although the admission of an error is a controversial issue with respect to legal liability, as professionals pharmacists have an obligation to "make it right" if a patient suggests that an error has been made. Reviewers with experience on Discipline Committees of the Provincial Regulatory Authorities suggest that often an aggrieved party is more upset by the way an error is handled than the actual error itself. A patient's inconvenience and distress should be recognized and acknowledged.
Potential error situations should be handled promptly, with courtesy and professionalism.
"Handling a Dispensing Error", Rantucci (1995) provides a case example of how to handle a medication error, the right way and the wrong way, and stresses the importance of effective communication with the patient about the error.
"Handling Dispensing Errors", Pritchard (1995) offers a brief review on dealing with medication errors and described two documents available from Ontario College of Pharmacists:
- Suggested protocol for handling dispensing errors (with underlying principles for dealing with situation) and
- An incident form for documentation
Commentary on the article's flow chart for dealing with medication errors from toolkit reviewers included:
"The initial contact between a patient alleging a dispensing error and pharmacy is usually conducted over the telephone. It is suggested that if the error can be confirmed over the telephone the pharmacist should offer to send the replacement medication rather than ask the patient to return to the pharmacy immediately."
"After "No Discrepancy" the flow chart states "reassure patient/agent". The pharmacist should also consider that the physician might have inadvertently ordered the wrong drug or the correct drug with the incorrect patient name on the prescription form. Another step for pharmacists is to "confirm with prescriber if necessary" and then "reassure patient/agent".
Work re-design to prevent errors
The article "US experiment with a two-tier dispensary" published in Pharmacy Practice briefly describes an experimental two- level dispensary designed to minimize interruptions during dispensing process.
In "Supervising technicians to enable efficient and effective patient care", Janke et al describe effective techniques for supervising technicians to enable efficient and effective patient care. The article provides guidelines and tools for assessing the required level of pharmacist supervision of technicians for different functions.
Bibliography
1. Causes and Prevention of Medication Errors. Institute for Safe Medication Practices. 1997
2. US experiment with a two-tier dispensary. Pharm Pract 1995:(11)9; 18
3. Rantucci M. Handling a Dispensing Error. Pharm Prac 1995 (11)8;
4. Pritchard B. Handling Dispensing Errors, Pharmacy Connection 1995: Mar/Apr;27
5. Janke KK MacDonald ML. Supervising technicians to enable efficient and effective patient care. Can Pharm J 1997: Dec/Jan;35