Medication Dispensing Errors – Policies & Procedures – Pharmacy Consulting

Medication Dispensing Errors – Policies & Procedures:

Medication dispensing errors are a Pharmacy “fact of life” and we all deal with them. Having Policies and Procedures in place to assure that your Pharmacy adheres to current best practices is a must. This pertains to both preventing medication dispensing errors, as well as dealing with the documentation and reporting of errors that do occur.

A study performed over a 7 month period at a major hospital revealed the following regarding medication dispensing errors:

-A total of 140,755 drug dosages were prepared by Pharmacy technicians and 3.6% contained an error.
– 0.75% of the medications prepared left the Pharmacy with an error after verified by the Hospital Pharmacist. The Pharmacist “caught” only 79% of the medication errors using the hospital’s “routine verification” procedures.
– 23.5% of the medication errors that left the Pharmacy undetected could have resulted in an adverse effect if given to the patient. Of these, 28% were considered “serious” and 0.8% were classified as “life threatening”.
– The results of the study then revealed that the dispensing errors were:
Incorrect Medication: 36%
Incorrect Dosage or Strength: 35%
Incorrect Dosage Form: 21%

Many medical professionals found these numbers to be “scary” and “unacceptable”. It was noted that had the Hospital Pharmacy instituted up to date policies and procedures with better documentation, that a majority of the medication dispensing errors would have been “easily avoided”. This study directly ties in to the latest data released recently by The Institute for Safe Medication Practices (ISMP). ISMP diligently works to identify major medication safety issues, plus promoting the sharing of procedures and strategies that would lead to a reduction & prevention of medication dispensing errors in order to protect patients and consumers.

At ASHP Midyear, ISMP revealed the classes of drugs most frequently documented for errors and suggested that safety strategies were the key factor that we all must develop and adhere to going forward.

Darryl S. Rich, PharmD, MBA, FASHP, medication safety specialist for ISMP, presented the top 5 high-alert medication classes based on data from 2016. Opioids, antithrombotics, and insulins topped the list, followed by antipsychotics and antibiotics. Rich noted that data pegged wrong dosage as the top reason for adverse events in most cases, except in the use of antibiotics, for which wrong drug was the top reason.

The point is that it is now critical that all Pharmacies develop Policies and Procedures that both minimize the occurrence and potential for medication dispensing errors, plus have a plan in place to deal with the errors that inevitably will occur. This is being called “the Age of Documentation” by many and everyone must show that they have “best practices” in place, PLUS follow these “best practices” to the best of the their ability. Without doing this crucial documentation, not only will the occurrence of medication dispensing errors increase, but liability will exponentially increase as well.

We at HCC strongly advise that you develop Policies and Procedures that ensure “best practices” are implemented at your Pharmacy operation immediately. In addition, document and report all medication dispensing errors that occur (and we all know that they will). Another instance of the old cliche that “an ounce of prevention is worth a pound of cure” that we here at HCC have been advising our clients to adhere to for over 27 years now.

As always, please contact us here at HCC if you have any questions regarding development of policies and procedures related to medication dispensing errors. If you already have them in place, perhaps a review by an objective (and experienced) third party is a good idea? With over 27 years in the Pharmacy Consulting business, HCC can assist with expert advice in any area of your pharmacy business or practice. We urge you to contact us today to see how our Pharmacy Consulting services can help. With a full-time staff of in-house Pharmacy Consultant specialists, HCC can answer any questions that you may have in all Pharmacy settings. Contact us online or call us today at 800-642-1652 for a free consultation.


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