In the pharmacy, errors can lead to dangerous outcomes
Accidentally switching one medication for another can cause an adverse event if it reaches the patient
Understanding how to prevent or catch mistakes before they occur keeps the patient safe and maintains trust in the healthcare system
Adverse Events
An adverse event is an undesirable outcome of medical treatment
This can be a reaction to a specific medication, a preexisting allergy, a malfunctioning medical device, or an error in administrating the medication
Over 200,000 patient deaths annually are a result of avoidable medical errors
This is why these strategies are essential to protecting our patients
Prevention Strategies
1. Standard Operating Procedures (SOPs)
A detailed outline of specific pharmacy procedures sets the expectation and standard for workflow and reduces the likelihood of errors
Some errors this strategy mitigates…
- Expired medications: At no time should outdated medications be left on the shelves. Per the SOP of many pharmacies, pull these 2-3 months from their expiration date to prevent these medications from reaching the patient
- Incorrect administration technique: Incorrectly administering a medication to the patient can have grave consequences
- Incorrect preparation: With an up-to-date SOP, there should always be a reference for the proper method of filling or stocking procedures
2. Technology Integration
No, the robots are not taking over our jobs (lol). They add a safe feature to double-check our work so we can focus on the patient
Automated dispensing systems reduce human errors like spilling tablets, touching medications, or miscounts
Electronic health records (EHR) ensure patient records are properly stored and safe from prying eyes
These also prevent medication errors such as illegible writing on handwritten prescriptions
3. Medication Management Systems
Drug interaction alerts in these systems alert staff of potential dangers between two medication therapies
They are also helpful in preventing dose duplications or omissions (medication is not administered)
4. Upstream Error Prevention
Because we know common ways mistakes arise, we can make various changes to prevent confusion
- Tall man lettering: Emphasizes sections of drug names that may appear similar (ex. clomiPHENE vs clomiPRAMINE)
- Separate storage: High-risk or hazardous medications should be on separate shelves or rows to prevent potential mix-ups
Related: Look Alike Sound Alike Medications
5. Environmental Controls
One of the biggest causes of medication errors is distractions
Keeping a clear, well-organized workplace prevents many of the possible distraction-type errors
Another common error is inadequate monitoring, or running out of stock of certain medications leaving patients missing doses while they wait for the pharmacy to order more
Always keep an eye on medication stocks in the pharmacy
If a medication is fairly common, it needs to be ordered more often in higher quantities
Many retail pharmacies have a “fast mover” section that stores all the most popular medications such as…
- Atorvastatin
- Eliquis
- Metformin
- Omeprazole
- Pantoprazole
- Proair (albuterol)
- Sulfamethoxazole/trimethoprim
6. Medication Administration
A patient’s medication should be given as written by the practicing physician
An incorrect dose error would be a dose any higher or lower than the prescribed dose
Some medications must also be taken at a specific time, if a medication is taken at the wrong time it may result in an adverse event