Dispensing Error: K.SAMINATHAN. M.pharm, M.B.A, (P.HD) Allianze College of Medical Sciences

DISPENSING ERROR
BY
K.SAMINATHAN. M.pharm, M.B.A,( P.hD)

Allianze college of medical sciences
1
DEFINITION OF MEDICATION ERRORS
• Any preventable event that may cause or lead
to inappropriate use or patient harm while the
medication is in the control of the health care
professional, patient, or consumer.
POINT OF ERROR
Prescribers (doctors),
Dispensers (pharmacists)
Nursing staff
Patient himself
2
TYPE OF MEDICATION ERROR
Prescribing error
Omission error
Wrong time error
Unauthorized/ wrong drug error
Dose error
Dosage form error
Drug preparation error
Route of administration error
Administration technique error
Deteriorated drug error
Monitoring error
Compliance error
Other medication error
3
Types of Medication Errors
Prescribing Incorrect drug product
error selection (based on
indications, CI, known
allergies, existing drug
therapy), dose, dosage
form, quantity, route or
rate of administration,
conc., or instructions for
use authorised by
physician; illegible Rx or
med orders that lead to
errors
K.SAMINATHAN. M.pharm, M.B.A,( P.hD) 4
Omission The failure to administer
error an ordered dose to a
patient before the next
ordered dose or failure to
prescribe a drug product
that is indicated.
The failure to administer
an ordered dose excludes
patient’s refusal and
clinical decision or other
valid reason not to
administer.

Wrong time Administration of
error medication outside a
predefined time interval
from its scheduled
administration time
Unauthorized/ Dispensing or
administration to the
wrong drug
patient of medication not
error authorized by a legitimate
prescriber

Dose error Dispensing or
administration to pt of a
dose that is > or< than
amount ordered by
prescriber or administration
of multiple doses to pt
Dosage form Dispensing or

error administration to pt of a
drug product in diff dosage
form than that ordered by
prescriber
7
Drug Drug product incorrectly
preparation formulated or manipulated
error before dispensing or
administration
Route of Wrong route of

administration administration of the
correct drug
error
Administration Inappropriate procedure or
technique improper technique in the
error administration of a drug
other than wrong route
8
Deteriorated Dispensing or administration
drug error of a drug that has expired or
the physical or chemical
dosage form integrity has
changed
Monitoring Failure to review a
error prescribed regimen for
appropriateness & detection
of problems, or failure to use
appropriate clinical or lab
data for adequate
assessment of pt response
to prescribed therapy
9
Compliance Inappropriate patient
error behavior regarding
adherence to a prescribed
medication regimen
Other Any medication error that

medication does not fall into one of the
error above predefined types
10
11
Categorizing Medication Errors
• Category A – has capacity to
cause error
• Category B – error occurred

• Category F – error resulted in
temporary harm and required
hospitalization
but did not reach patient
• Category C – error reached
patient but did not cause harm
• Category G – error resulted in
permanent harm
• Category H – error required
• Category D – error required
monitoring or intervention to
preclude harm intervention to sustain life
• Category I – error contributed
to or resulted in death
• Category E – error resulted in
temporary harm and required
intervention 12
DISPENSING ERRORS
• Errors that occur at any stage during the dispensing

process
• These errors may undermine the patient’s trust in the
pharmacist and increase the risk of litigation procedures
• Selection of the wrong strength/product.
• Mainly caused when two or more drugs have a similar
appearance or similar name (look –a-like/sound-a-like).
• Other potential dispensing errors include wrong dose,
wrong drug and wrong patient.
13
DRUG NAMES THAT MAY BE CONFUSED
14
APPERANCE CONFUSION
15
16
17
18
IMPROVE: DRUG DISPENSING
1.Use generic names as far as possible.

Use furosemide (Frusemide) instead of Lasix
Use diclofenac instead of Voltaren.
Use domperidone instead of motilium
2.Eliminate drugs with similar drug names.
3.Beware of drugs with similar appearance.
Improve – drug dispensing procedure
Staff training.
State the drug attributes to be checked.
Drugs should be cross-checked after dispensing.
Checked by the doctor before issue to patients.
19
MINIMIZING DISPENSING ERRORS
• Ensure a safe place for dispensing process.

• Use different brands or separate products
that look alike.
• Practice good housekeeping habits.
• Be knowledgeable of high risk drugs.
• Keep interruptions to a minimum and
maintain workload at a safe and manageable
level. 20
22
WHY REPORT MEDICATION ERRORS?
• Improve patient safety

• Development of valuable educational services
WHO SHOULD REPORT MEDICATION ERRORS?
• Pharmacists
• Nurses
• Physicians
• Other health care professionals
23
24
25
26
27
CONCLUSION
• Health Care professional shares the responsibility
for identifying factors to medication errors and for
using that knowledge to reduce occurrences.
• Medication errors cannot be ignored when they

occur due to the risk of medical litigation as well as
the patient’s well being.
• Medication safety solutions must be upgraded.

Those who fall behind have a greater risk of patients
getting seriously ill or death
• Preventing Adverse Drug Events which result from
errors will reduce the likelihood of them occurring.
• A multidisciplinary approach to solving the problem
must be promoted.
• An attitude of “no blame” should be
adopted. 28

THANK
YOU

Dispensing Error: K.SAMINATHAN. M.pharm, M.B.A, (P.HD) Allianze College of Medical Sciences

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DISPENSING ERROR

K.SAMINATHAN. M.pharm, M.B.A,( P.hD)

K.SAMINATHAN. M.pharm, M.B.A,( P.hD) 5

K.SAMINATHAN. M.pharm, M.B.A,( P.hD) 6

Dosage form Dispensing or

Route of Wrong route of

Other Any medication error that

• Category B – error occurred

• Errors that occur at any stage during the dispensing

1.Use generic names as far as possible.

Improve – drug dispensing procedure

• Ensure a safe place for dispensing process.

• Improve patient safety

WHO SHOULD REPORT MEDICATION ERRORS?

• Medication errors cannot be ignored when they

• Medication safety solutions must be upgraded.

Allianze college of medical sciences

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