Prescription Dispensing Error Study – Develop Policies and Procedures

In a recent three year study performed by a news station in Maine, they found that out of 218 disciplinary actions taken by the Maine Board of Pharmacy, 41 of the actions were for misfilled prescriptions dispensed by a pharmacist. The study reviewed a three year period and documented over three dozen dispensing errors with patients receiving the wrong dosage or the wrong medications, some with “significant” side effects. When a pharmacist gives a patient the wrong drug or dose, it can result in harm to the patient that can lead to both lawsuits and obviously disciplinary actions.

Here are several examples of the documented prescription misfills found in the study:

– In one case, the Maine Board of Pharmacy reported that instead of getting a drug to treat seizures, the patient got an antibiotic to treat anthrax. According to the report, the mistake caused “adverse health effects.
– In another case a customer got thyroid pills instead of the prescribed antibiotic.
– A customer was supposed to get Vitamin D but instead got a prescription to treat depression and anxiety.
– Another misfilled prescription documented in the study caused the patient “weakness, confusion, delirium and congestive heart failure,” according to the report.

Misfilled prescriptions are a fact of life. Pharmacists are after all humans and prone to making a mistake occasionally. None of us are perfect. However, records from the study showed that penalties imposed by Board as disciplinary actions ranged from a fine to further education to license suspension. This is not to mention the bad publicity to both the pharmacy and pharmacist that resulted. The study also stated that we’re likely to see more complaints about misfilled prescriptions in the future because there’s a bigger focus on health insurance and pharmacy costs. The Institute of Medicine estimates medication mistakes harm 1.5 million Americans a year. Keep in mind that these reported misfills may be just a fraction of the mistakes that are made. Only closed cases are public and many customers who find errors, won’t file a complaint.

It is important that every pharmacy has written policies and procedures to document the checks in place to make sure the right medicine is provided to the right patient. Part of the problem that was revealed in the study was that many pharmacies did not have written policies and procedures on filling prescriptions, plus if they did the policies and procedures were not followed correctly. This is just another example of the old cliche that “an ounce of prevention is worth a pound of cure”. Going the extra step when dispensing medications to ensure that no mistakes are made as part of your dispensing practices is now being seen as the “norm” in our profession. It’s not required by state or federal law, but CVS is also now adding a physical description of the pill on the label to make sure it matches what’s in the bottle. Other pharmacies could start doing the same.

Does your pharmacy have written policies and procedures in place regarding the filling and dispensing of medications? Do you ensure that if a mistake is made that you have documentation that will be viewed as up to standard that every step was taken to dispense the proper medication and dosage to your patients? Is your staff properly trained and able to document situations where a mistake is made? If not, then contact HCC today to see how we can help. Healthcare Consulting has been a full service Pharmacy staffing and consulting firm that has been in business for over 25 years. HCC has been helping pharmacies plan, prepare and deal with issues such as these since 1989. Just a few examples of our services include:

– Development of Policies and Procedures
– Employee Training- Patient Consultation Documentation
– Pharmacy Management Consultation

Although we all hope that we will never personally deal with such situations cited in the study above, I strongly urge you to be prepared. Contact us on line or call us today for a Free Consultation at 800-642-1653 to discuss how we can help you.

Bob Miller

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