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;43:191200.

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Use of outdated or incorrect references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 23 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
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 childs 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 error-
prone 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:
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
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

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 technicians
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, 1997:10011.

 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 patients 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 drugs 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 manufacturers 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;43:191200.

Ukens C. Deadly dispensing: an exclusive survey of Rx

errors by pharmacists. Drug Topics. March 13,
1997:10011.