Minimizing Dispensing Errors

Pharmacists are multi-tasking professionals. Most of the pharmacy works are done and accomplished by a registered
pharmacist. From the management down to client care, a pharmacist is always needed in a pharmacy to effectively
provide optimum service to the community with good quality and effective medicines. Pharmacist's important role is to
interpret prescription orders, dispense drug order and counseling patients regarding all information needed to know
about their medicine. But because pharmacists are multi-tasking individuals sometimes the most important key function
they must be is disregarded. Due to this circumstance dispensing errors occur.

Dispensing Errors
Dispensing Errors are errors committed by pharmacists, pharmacy technicians and/or any personnel who are involved in
dispensing medicines before, during and after the transaction with the client. Errors can be either human error,
technical, procedural or machine errors. These errors could be associated with the drug error, labeling error and
issuance error.

Classification and Type of Dispensing Errors

1. Drug Error
a. Incorrect drug dispensed
b. Incorrect strength dispensed
c. Incorrect dosage form dispensed
d. Expired/deteriorated/substandard drug
e. Failure to supply drug

2. Labeling Error
a. Incorrect drug name on label
b. Incorrect strength on label
c. Incorrect dosage form on label
d. Incorrect directions/warning on label
e. Incorrect patient name on label
f. Incorrect ward/cost center/ prescriber
h. Completely wrong label on bottle

3. Issuance error
a. Incorrectly given to wrong patient
b. Incorrectly bagged

Contributory Factors Affecting Dispensing Procedure Leading to Errors and Possible Remedies to Prevent them.

1. Workload and Pressure

Prevention: Take each work at a time. Finish one task before engaging to another task. This can help you to
prevent error. Focusing on a single work can eradicate error. Relax from time to time to remove pressure.
2. Similar drug names and levels
Prevention: Separate drugs with the most similar names away from each other to avoid confusion. When sorting
out a drug and find out that the drug has similar drug name or packaging syle try to read the label's information
to differentiate between them the required drug. The best thing to do is consulting you superior or supervisor
regarding this.
3. Incorrect display or storage area
Prevention: See to it that the medicines are properly displayed in an arrangement of either therapeutically,
alphabetically or an arrangement desired that can be easily memorized and remembered. Shelves and storage
areas should be free from any blockage or barrier that can hinder identification and acquisition.
4. Staffing levels and job dissatisfaction
Prevention: Poor benefits and incentives can insecure staff. Poor basic provisions such as drinking water rest
days and breaks can lead to personnel inefficiency. Conflict about seniority and superiority can also be a
problem. It can be fixed by discussing the problems in an open forum meeting or one on one discussion.
5. Poor eye sight, handwriting and listening skills
Prevention: Poor eye sight can be corrected using eye glasses or contact lens. Instead of cursive writing one may
choose all capital letters to clearly understand what is being indicated. While poor listening can be corrected
through use of earphone, headset or noise reduction gadget when using phones to minimize noise. When
communicating with each other physically speak clearly and be near to each other to understand what is being
talked.
6. Interruptions/distractions and Noise
Prevention: Avoid too much conversation and gossip among each other’s if the topic is not related to work.
Television, loud radio sounds, or even social media visiting much not be done during work time.
7. Lack of space or design of dispensary
Prevention: A pharmacy with a scarce area to work on can lead to confusion, so that preparations and
dispensing of medicines will commit error. Same as for design of dispensary, when the design is inappropriate
errors may occur. The best thing to do is to maximize the area. Provide storage area for other stocks, fluids and
boxes. If the space is just enough and storage area cannot be provided, shelves and gondolas can be affixed on
walls. This will help to occupy other spaces around your pharmacy that are not being used much. Other products
can be stored there and freeing floor spaces with unnecessary boxes, stocks and others. Dispensary must
complement with the design of the pharmacy to maximize the use of it.
8. Lack of staff knowledge, staff inexperience and inflexibility
Prevention: Conduct assessment test regarding their performance. This will help you to identify whom of your
staff and personnel really need special training, seminars or even attending another crash course. These
solutions can eliminate incompetency, inexperience, lack of knowledge and inflexibility of your staff.
9. Misread and complex prescription and ambiguous directions
Prevention: Approach others opinion regarding a doubtful prescription. Two heads are better than one!
Interview patient to find clarity to the order. The best way to do is to communicate with the patient's attending
physician and clarify his medication order for his patient.
10. Failure to check
Prevention: Should be included in the standard operating procedures that every time a drug is to be dispensed
checking should be done, any step in the procedure, so that drug to be dispensed will correspond to the
prescription order given to patient. Best time to check is when the patient will pick up the medicines. The
pharmacist can itemize the medicines in front of the patient. In this case the patient sees the product
completeness and the pharmacist double or triple checks the medicines.
11. Lack of procedures and/or failure to follow standard operating procedures
Prevention: Should provide and mandate every staff to follow step-by-step procedures. Everyone must have a
copy of it and must be obedient to it.
12. Poor communication
Prevention: Avoid the use of communication barriers such as earphones, loud speakers, television, jammers and
alike during work. If possible, to do so pharmacy should not be placed along traffic and highways.
13. Computer software
Prevention: Should be user friendly, easily to manipulate and access and have highest security protection
against hackers, malwares, ad wares and alike.
14. Proximity of drugs on shelves
Prevention: Medicines should be reachable. Fast moving drugs should be placed where can be easily accessed.
Package names should be visible always. If the medicine is located in the highest level in the shelves provision of
a foot stool or small ladder must be available.
15. No breaks
Prevention: Exhaustion can lead to dispensing error. Break or recess can help to refresh ones mind and body. A
relaxation for a moment can re-energize and revitalize staff again.
16. Hunger, Fatigue, and Stress
Prevention: Breaks can help to resolve hunger, fatigue and stress. Weekly rest at least 2 days may lessen fatigue
and stress from work.
17. Lack of concentration
Prevention: Avoid day dreaming, gossiping and other materials that can take away your concentration from you
work.
18. Lighting
Prevention: Pharmacy should be well-lighted especially in the dispensary, counter, and shelf areas where the
drugs are mostly located. A well-lighted pharmacy can improve the identification and acquisition of the right
drug without any mistake.
19. Lack of support/assistance and lone worker
Prevention: Chief pharmacist and supervisors should be available at all times when a pharmacy technician or
other pharmacy staff needed their assistance. Do not let personnel works alone, especially when the
prescription filling is too much. There must be at least two or three personnel in every shift to complement with
the gravity of work.
20. Lack of cleanliness and orderliness
Prevention: The pharmacy must always be clean and neat. Empty boxes, bottles, scrap papers and other clutters
should not be messed or mixed with the good stocks to avoid mistake. Sometimes when the pharmacy is not
orderly and neat the personnel's mind can attract disorganization also. Regularly cleaning of the pharmacy is a
very important to do.
21. Personal and Family problems
Prevention: Personal and family problems are the most cause of errors during dispensing. Because when
personnel have a problem his focus is being divided between work and problem. He can think his problem while
working, thus, causing him to error. Best way to do is to ask for a leave or vacation. During this time off you can
resolve your personal or family problems and come back to work with full concentration again.

Errors and mistakes are sometimes inevitable and unavoidable. They usually happen unexpectedly. Pharmacists are also
human beings and tend to err also. But because of the seriousness and gravity of their function and responsibility that
can lead to patient's harm or even death mistakes has no room to their profession. I, too, had experienced dispensing
errors twice before but not that too serious. I believe that every pharmacist had experienced it. Nobody is exempted to
it. Maybe in your entire career at least once or twice you have committed it. Instead errors staying on you, you can turn
that in to a positive perspective. Take your dispensing errors experience as your learning lesson. A lesson that should not
be committed anymore and teaches you to be prudent and to love your work even more. Everybody deserves second
chance. Remember that you have earned your degree with hardship and you do not want to take it from you that easily.
Or worst of all you can be penalized for your wrong doings and be sentenced and thrown against bars that you do not
want to happen to you. Love your work, be happy always and smile each time a customer enters your pharmacy.