Preventing Dispensing Errors

• Dispensing errors can have severe consequences
• Learning about errors is vital for preventing future occurrences

Types of Dispensing Errors

• Picking errors happens with administering a differing medicine or the incorrect strength/form of the proper ingredient
• Counting errors happens when dispensing the wrong quantity of the correct medicine
• Labelling errors happens with incorrect dosage, the incorrect patient name, incorrect drug name, or drug strength
• Dispensing a medicine after it has already expired is an dispensing error
• Handout errors happens when giving medications to the wrong person

Data on Dispensing Errors

• The National Reporting and Learning Systems (NRLS) gather data from community pharmacies in England and Wales
• Data from 2005-2010 of 14,704 incidents reported that the most common errors were:
  • Wrong dose/strength (30.3%)
  • Wrong medicine (28%)
  • Wrong formulation (12%)
  • Wrong quantity (9%)
• 92% of errors caused no harm
• Less than 1% (n=29) resulted in severe harm or death

Consequences of Dispensing Errors

• Dispensing faults are criminal offenses, which could lead to prosecution
• Patients can sue a pharmacist for damages if they believe they were negligent
• Dispensing errors can lead to General Pharmaceutical Council investigations

Reducing Dispensing Errors

• Pharmacists are advised to maintain records of their errors and near misses of preventable errors
• Reviewing those records should occur during regularly held meetings
• Open and honest communication is vital to prevent recurrence

Common Dispensing Errors

• When medicine names or packaging looks similar
• When medicine has expired
• When there is an incorrect calculation
• When misreading a prescription

Error Type: Similar Names or Packaging

• Medications with look-alike-sound-alike (LASA) names cause more errors
• The National Pharmacy Association reports that 23% of mistakes are from similar names
• Examples include Allopurinol/atenolol, Amitriptyline/amlodipine, and Indapamide/imipramine
• Ensuring medications are not stored close by and confirming the medication with a colleague before dispensing are solutions

Real Life Case: Martin White

• A pharmacist in Northern Ireland named Martin White dispensed Propranolol instead of Prednisolone
• Ethna Walsh with COPD received a prescription for a course of Prednisolone (6 daily of 5mg tablets for 5 days)
• Martin White gave the patient a prescription of propranolol 40mg by mistake
• Ethna Walsh started having difficulty breathing and died after taking the first dose (6 x 40mg Propranolol)
• Martin White was sentenced to 4 months of imprisonment, suspended for 2 years, after arguing the similarities of the packaging

Expired Medicines

• Expired medicine can be ineffective if medicince is used after expiration date
• Medicine should not be expired while someone is prescribed it and still taking it
• Pharmacies should establish a standard procedure for checking dates and removing outdated stock
• Stock rotations must be performed so newer stock goes behind any older stock already on the shelves

Error Type: Incorrect Calculations

• This is a common type of dispensing error
• This is especially true with medicines for children
• Solution:
  • Have a colleague check calculations or take a break and recheck
  • Double check the dosage to be reasonable for the patient

Real Life Case: Peppermint Water Case

• Multiple other failures related to the equipment used, unclear formula, and employees' understanding were also noted
• After the father administered the medicine, he realized something was wrong
• A 4-day-old infant was prescribed 150ml of peppermint water
• Incorrect dilution computations led the prescription to be incorrectly dispensed
• The infant was admitted to the hospital and lived for 2.5 weeks before succumbing to brain damage

Real Life Case: Lucas Holzscheiter

• A 7.5-month-old at London Hospital received an overdose of Phenytoin 10x higher than prescribed
• The overdose occurred because of miscalculations by the prescriber and oversight of clinical employees

Error Type: Misreading Prescriptions

• Prescriptions that are difficult to read is a common causes of dispensing errors
• Latin letters that is poorly written or misread is a common causes of dispensing errors
• When the abbreviation "mg" is used in the dosage line instead of the amount is a common causes of dispensing errors
• Asking another colleague to read the Rx is the best solution

Real Life Case: Ranitidine (Part 1)

• A two month old baby under pediatric consultant got a prescription for ranitidine solution 75mg/5ml at 0.5ml tds
• The patient was to receive 2.5mls TDS = 7.5mls daily
• The pharmacist dispensed ranitidine and labelled the medication "Half a 5ml spoonful to be taken three times a day"
• The error was noticed by the baby's mother after 4 days
• Mom sought clarification from the pharmacist but pharmacist said the dosage was correct

How to Handle a Dispensing Error

• GPhC gives guidance regarding handling errors
• Handling errors ensures patient safety as the top priority
• Handling dispensing errors need to be done Honestly and Openly
• Taking accountability of any mistake will prevent problems and negative outcomes

Real Life Case: Ranitidine (Part 2)

• Initially, the pharmacist said that he had discussed the situation with the doctor when he had not
• The pharmacist then dispensed the medication again, but this time at the correct dosage
• The mother telephoned the doctor, and had learned that this was unture when she spoke to the doctors receptionist
• Mother confronted pharmacist who admitted he had not spoken to the doctor
• Mom took the baby to A&E imediatly
• Later that evening, the pharmacist apologised for the error in a call to the mother

Duty of Candor

• Duty of candor is acting truthfully and honestly
• It applies to all healthcare professionals
• Those with duty of candor must do the following:
  • It's important to inform a patient of what went went
  • It is important to always apologize to the patient
  • Need to offer a solution and support so that the issue doesn't happen again if possible.
  • Need to fully explain the short term and long term affects of the error

Dishonesty

• Trust can only be earned if professionals working with honesty and integrity
• Public confidence in any profession can only be Maintained if there is trust
• The worst thing to do when an dispensing error is made is attempt to cover it up or ignore it
• It must be taken care of immediately after learning of it

Real Life Case: Ranitidine (Part 3)

• Error was not as big of a deal as the lie made up
• The pharmacist dishonestly tried to cover up a dispensing error
• The Chairman called pharmacist's behaviour disgraceful and wholly inappropriate"
• The GPhC Fitness to Practise Committee appeared before the pharmacist
• There was no harm toward the baby
• The pharmacist unnecessarily caused anxiety and distress to the mother
• The pharmacist was suspended from the register for 4 month