Pharmacists are human, and humans make mistakes. With the greatest will in the world and with the best training provided and implemented, we can still make mistakes. The best pilots on the planet can make mistakes.
Being a pharmacist, or working in a pharmacy, comes with huge pressures and responsibilities. Patients’ lives are in our hands. I got great satisfaction from knowing that I made a positive impact in peoples’ lives every day, but sometimes the pressures of our working environment can lead to mistakes being made.
Transcription errors happen regularly, the vast majority of which can be amended at the source. Having multiple checks at this stage of the dispensing process can reduce the potential for a mistake to be made. It is also vital to ensure that patient identity is verified and that their medical history has been made available to you the pharmacist. It is useful to know the person’s age, gender, allergies and what other medications they may be taking.
Second guessing and assuming, are frequently associated with dispensing errors. We assume that repeat prescriptions were checked in the previous instance. If there is any ambiguity about a script, ask the doctor for clarification on abbreviations, dosage and/or decimals placings. All verbal communications regarding a script should be documented to encourage accountability, transparency and to keep us all safe.
Misplaced 0’s, decimal points and faulty units are a common cause of medication errors. Unlike with our mobile phones, there’s no Autocorrect when typing up prescriptions. A misplaced decimal point could mean the patient receives ten times the amount/dosage required. This could cause serious illness, or even death. Such an error can be prevented by storing only single strength medications in your pharmacy. On occasion, these mistakes can be found during the counselling procedure.
Beware similar drugs. Whether they sound the same or look the same, you need to be alert to detect the differences. We can get complacent at times. It’s easy to make mistakes and confuse drugs when you’re trying to do another 1,000,001 things at the same time. But you don’t want to dispense methadone instead of methylphenidate! Look at your IT system, it is possible to set up alerts that are activated when you are dealing with high risk drugs that are prone to being confused with others.
As stated before, pharmacists are regularly trying to do 1,000,001 things at once. We have patients to deal with, staff to organise, stock to control and there’s also the minor task of dispensing life-saving medicines. Committing your staff to a regular and regimented workflow cycle can help everyone get into a rhythm and reduce dispensing errors. When possible, try to ensure that multi-tasking is kept to a minimum. (I know, this all sounds great in an ideal world…)
I’ve worked many days without taking a lunch break, but you should really try to. I’d rather a patient waited an extra 15 minutes on a prescription than receive an incorrect one. Try to take a quick walk at some point throughout the day. It’s good to escape the building, or those four walls that your stuck within. We need an escape at times, allowing us to come back to the workplace re-energised and refreshed. I went through a phase of eating salmon at lunch time because I heard it was, ‘great brain food.’ If you want to read more about healthy eating as pharmacist - check out our blog about that important topic.
Fail to prepare, prepare to fail. Setting off on the correct footing in the workplace can help to reduce errors. Ensuring that stock is properly marked and stored can help to keep track of resources. It may be helpful to store ‘look-alike’ drugs in one place, encouraging people to take extra caution when working with such medications. The basics are important too, when was the last time you completed a stock expiry check? Is your dispensary clutter free?
Repeat checking and counter-checking is an important strategy, and may be viewed by many to be a luxury enjoyed by larger teams with more resources. We encourage involving two persons in the dispensing process as much as possible. But you already know that, you don’t really need me to tell you it again.
Counselling not only benefits the patient, it also gives us a chance to check what has been prescribed, the dosage and we can live with confidence that we’ve provided the best possible service for our patients. Open the boxes or packaging to show the patient what drugs they will be consuming, and give yourself a chance to ensure that you’re providing the correct medicines.
How- How much has been dispensed?
Expiry - How long has the medication been prescribed for?
Label - Check that the labels are correct and easy for the patient to understand
Product - Is this correct product being delivered? (Dose and strength)
Blog’s like this can be useful to challenge us, and to help prevent complacency from setting in. If we’ve made just one person think differently about how they approach their work, for the better, then it’s been a success.
Do you have any tips for reducing dispensing errors? We would love to hear your comments.
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