October 10, 2019
Inside: Medication errors can prove deadly for your patients—here’s how to avoid them.
Mistakes will inevitably be made in your pharmacy, but some mistakes are worse than others. In the case of a medication error, an absent-minded moment could have deadly consequences.
A medication error is when something happens that leads to medication being used incorrectly, which can potentially harm patients. These include errors on the pharmacist’s end, like dispensing the wrong dosage or dispensing the wrong drug entirely, and errors on the patient’s end, like skipping a dose or taking too much of a drug.
With proper precautions, you can safeguard against both kinds of medication errors.
A study in the American Journal of Health-System Pharmacy found that 15 percent of dispensing errors are caused by inaccurate transcriptions.
Don’t let a doctor’s messy handwriting result in a patient getting the wrong prescription. Since even small changes can result in negative consequences for the patient, be extra careful when it comes to decimal points and abbreviations.
If you have questions about what’s written on a prescription, don’t just give it your best guess. Contact the physician for clarification and document what they say.
Some prescriptions have names similar enough that you may accidentally dispense one for the other—for instance, Prilosec and Prozac.
Obviously, a patient getting the completely wrong medication can have adverse effects on their health. Familiarize yourself with drugs that have similar names and take extra care when you dispense them to ensure nothing’s been improperly swapped out.
The FDA and Institute for Safe Medication Practices recommend adopting Tall Man Letters when dealing with these look-a-like and sound-a-like drugs.
The Tall Man system uses bolded, uppercase letters to distinguish between similar-looking drug names, which draws attention to their differences.
The ISMP has put together a list of lookalike drug names and standardized Tall Man styles so you can implement the system in your pharmacy and avoid confusion.
Keep your pharmacy organized and streamline workflow to minimize errors from pharmacists or other staff. When the workflow is optimized, pharmacists and technicians will have a well-established routine with fewer distractions.
Look-a-like drugs should be stored far away from one another. Separating them with storage bins or cabinets can help prevent mix-ups. Keeping the pharmacy well-lit can also reduce dispensing errors, as pharmacists and technicians can better see what medication they are grabbing.
Automation can help with this—using a pharmacy robot can reduce dispensing errors, especially when accompanied by a visual check from the pharmacist or pharmacy technician.
When your team is tired or stressed out, they’re going to make more errors. Staffing your pharmacy well ensures that everyone has the energy and attitude they need to do their best work.
In addition to making sure there are enough people behind the pharmacy counter, you should also give your team consistent breaks and time for meals. Not only will this practice help them re-energize, it also will reduce their workplace stress.
If you notice team members struggling, check in. You may need to adjust their workload to keep them at the top of their game and to protect your patients from medication errors.
Medication errors aren’t only limited to dispensing errors on the pharmacist’s end. Even if they’ve been given all the correct medications, patients may take them incorrectly. Those are considered medication errors, too.
In order to reduce these kinds of errors, pharmacists need to make sure their patients are well informed about their prescriptions. Poor communication has the potential to cause harm, even if the instructions may seem like common sense.
Be aware of these common mistakes that patients make:
Be sure to go over these potential mistakes with your patients to prevent any future errors.
Putting in place formalized adherence programs means that your patients will understand their medications better. In turn, they will be less likely to take them incorrectly.
Programs like medication therapy management (MTM) and medication synchronization mean that patients are more likely to refill their medication and less likely to skip a dose or take the wrong dose.
MTM is most often used as an avenue to talk to patients who are on several different medications to treat multiple conditions—these patients are the most likely to make medication errors at home.
Med synchronization takes adherence to the next level and lets patients pick up their medications for the month all at one time. This means that patients are much more likely to stick to their medications and pick up their prescriptions on time.
Patients are most likely to make medication errors when they are suffering from a cold or the flu. Feeling miserable, they come into the pharmacy and pull several different OTC medications off the shelf in the hopes that one of them will make them feel better.
This is a recipe for double dosing, which is the most common medication error patients make.
Make sure to counsel patients who are purchasing OTC medicines just like you would for those who are picking up prescriptions. A good tactic is to educate them on the active ingredients in their OTC medicines and the potential negative side effects. Then, make a recommendation on which products you think would work best so they don’t end up with a hodge-podge of things that might have negative consequences when taken together.
PBA Health is dedicated to helping independent pharmacies reach their full potential on the buy side of their business. The company is a member-owned organization that serves independent pharmacies with group purchasing services, expert contract negotiations, proprietary purchasing tools, distribution services, and more.
PBA Health, an HDA member, operates its own VAWD-certified warehouse with more than 6,000 SKUs, including brands, generics, narcotics CII-CV, cold-storage products, and over-the-counter (OTC) products.
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