Preventing

Dispensing Errors

Dr Najla Alabdulkarim
 Learning Objectives

• Describe dispensing errors causes

• 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
– Over 51 million dispensing errors per year

Flynn E, et al. J Am Pharm Assoc. 2003;43:191–200.

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 causes

1. Errors related to the work

environment
– Workload
– Distractions
– Work area
Errors related to the work environment:
Workload
• Can be caused by:
– Staff shortage
– Institutions demand to dispense certain number
of prescription
• 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 2–3 hours
• Brief warm-up period before restarting work tasks
• Require 30-minute meal breaks
Errors related to the work environment:
Combating Distractions
• Phone calls or question during prescription
entry or filling are the most common
distractors
• Combating Distractions
– Prohibit distractions during critical prescription-
filling functions
– Phones
• Fax machines, auto refill, voice mail
• Train support personnel to answer the telephone
Errors related to the work environment:
Work area

• Well designed work area should be:

• Free of clutter
• Ensure adequate space by returning unused
containers
• Store products with label facing forward
• Choose high-use items on the basis of safety as
well as convenience, use original containers
• Telephone placement close enough
• Adequate lighting, heat and humidity
• Eliminate noises (TV, radio)
Errors related to the work environment:
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 child’s ear
• Review published safety alerts for look-alike/
sound-alike drugs and frequent dispensing
errors
 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
2. 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
• Errors in labeling
Ambiguity in Written Orders

Amaryl 2 mg was misread as 12 mg

Tegretol 300 mg was misread as Tegretol 1300 mg

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 or i
– 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 Amoxicillin suspension
be poorly labeled 200mg/5ml
Mohamed Khalid ID:738473692
Give 2.5 ml every 12 hours for 7 days
Qty: 1 bottle
Rx date: 12/3/2020 Refill:0
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 parenteral
– 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

The narrow
side
The wide side
3. 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
 4. 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 technician’s
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
5. 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
 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!
 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 drug’s 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 manufacturer’s 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;43:191–200.

– Medication Errors, 2nd Edition, Published: January

2007, e-ISBN: 1-58212-092-7 ,
https://doi.org/10.21019/9781582120928