200mg and 500mg, as well as Epilim Chrono. 500mg. It scared me and made me realise the importance of always checking wha
Clinical
Module 1830
Medication errors From this module, you will learn: • The definition of a medication error • Common causes of errors in the pharmacy • Methods of avoiding and preventing errors • The consequences of errors
Philip Crilly, Pharmacy Teaching Fellow While the role of the community pharmacist has expanded to include the delivery of public health services, their traditional dispensing role has not subsided. In fact, the opposite is true. According to NHS Digital, more than 1,080 million items were dispensed in the community in England in 2015 – an increase of more than 50% compared with 2005 figures. Balancing the traditional dispensing role with the delivery of services is having an impact on pharmacists and their teams. With an increased workload and a significant pressure on time, the chances of making medication errors are now higher than ever. A 2014 report by Johnson et al. identified that work-related stress and medication errors are closely linked. It suggested that addressing this issue is essential if we are to ensure patient safety.
What is a medication error? The Medicines and Healthcare products Regulatory Agency defines a medication error as: “Any patient safety incident (PSI) where there has been an error in the process of prescribing, preparing, dispensing, administering, monitoring or providing advice on medicines.”
It further categorises these PSIs as either errors of commission or errors of omission. Within community pharmacy, the reported dispensing error rate is between 0.01% and 3.32%. However, this is only what is reported. The true figure may be much higher.
What are the common errors?
Reading prescriptions incorrectly Misreading a prescription can result in either giving a patient the wrong medication, or mislabelling the medication. Mislabelling is a particular issue for those dispensers who use labels when selecting stock. It is therefore important to follow standard operating procedures (SOPs) closely, and medications should be selected from the shelf using the prescription, not the label. This provides an extra safety net in case the prescription has originally been mislabelled. Picking up the wrong item With so many brands now producing similar looking and sounding medications, it’s easy for an error to occur when putting away and picking out stock. For example, a staff member may be working on ‘auto-pilot’ while sorting through a wholesaler delivery, and could mix up stock or assume that boxes that look the same are the same. Equally, there can be a similar risk of error
when dispensing. With the trend now to prescribe generically, some members of the pharmacy team may get confused if the medication is only available as a branded product. Some staff training may be required, to help prevent this mistake from occurring. The wrong quantity Very often the prescriber will state clearly the quantity they want dispensed. There may be times, however, when they only provide you with dosage directions and expect you to calculate the quantity required. One such example may be a prescription for prednisolone tablets, given as a reducing dose. Calculated incorrectly, this could leave the patient without essential medication. Other issues can occur when split boxes are used. Each pharmacy should have its own system for highlighting when a box of medication has been part-dispensed. This is necessary as it flags to the next person dispensing that the container is not full.
A 2009 literature review by James et al. noted that the most common dispensing errors involved incorrect: • dosage directions • drugs • strengths • forms. High workload and medications with similar packaging or similar sounding names were suggested in the review as the reasons for the majority of medication errors. The National Pharmacy Association (NPA) medication safety officer’s (MSO) report (tinyurl.com/medincidents-1) identifies the most common recently reported medication errors every three months, and is worth reading and sharing with your pharmacy team. It provides an opportunity to learn from others’ mistakes, which could ultimately reduce the risk of making similar mistakes in future.
chemistanddruggist.co.uk/update-plus
Module 1830 | Medication errors | 1 of 3
Pharmacist case study: unexpected strengths I vividly remember my first near miss as a pharmacist. I was working in a very busy store and was checking a prescription for Epilim e/c 200mg tablets. The tablets had been dispensed in a white box. I tipped the box out to check the quantity and – to my horror – there was a mixture of Epilim e/c 200mg and 500mg, as well as Epilim Chrono 500mg. It scared me and made me realise the importance of always checking what is in a dispensed box. Taking an extra 30 seconds ensured that the patient received the correct formulation and was safe from harm.
Wrong formulation Many drugs come in different formulations, which can lead to the wrong item being selected. Although at times this may seem trivial, it can make a huge difference to how the drug is absorbed from the body. Wrong formulations can be a particular issue for asthma inhalers and insulin devices. Extra care is always needed when dispensing these to patients, as incorrect formulations could have serious consequences on the patients’ health. Insulin in particular should be dispensed and then placed in a clear bag, so that the patient is able to verify that this is the particular brand they are using. This is a quick way to identify errors before they leave the pharmacy. Wrong dosing instructions Dosing errors can occur when calculations are not performed correctly. An example might be when a prescriber writes a dose in milligrams and expects the pharmacist to interpret this into a number of tablets or millilitres of suspension. The MSO report for October-December 2016 highlighted a situation in which a dose of 15mg daily – to be administered from a 10mg/
ml solution – was labelled as “Take 15ml daily”, instead of, “Take 1.5ml daily”. Errors like this – which could have led to a ten-fold overdose – can have very serious consequences for patients. All calculations should be worked out in a quiet part of the dispensary on a fresh piece of paper. It may be worth asking another member of the pharmacy team to do the same calculation, so that you can check your answer. Errors on hand-out or delivery Even if the rest of the dispensing process has gone smoothly, there are still real risks of medication errors during the hand-out or delivery of prescriptions. It has been known for patients to receive other people’s medications – particularly if names are similar. There may also be an element of complacency on the part of the person giving out the prescription, assuming that they know who a patient is without checking. Medications have also been delivered to wrong addresses or delivered to patients directly when they should have been given to a carer. Medications getting into the wrong hands can have very serious consequences, so particular care is needed at this stage of the dispensing process.
many pharmacists would class as high risk do not appear to feature. Instead, errors involving lowrisk medications appear to be more common. This may be due to the fact that pharmacy staff are more aware of the dangers associated with highrisk medicines, and are therefore more vigilant when dispensing them. For low-risk medicines, complacency may be a factor – particularly when constantly dispensing the same types of medication every day. In the most recent MSO report, the following drugs had been mixed up: allopurinol/atenolol; amlodipine/ atorvastatin; amitriptyline/amlodipine. Pharmacists need to remember to stay vigilant when dispensing all prescriptions, and not take for granted those medicines they dispense on a regular basis.
Methods of avoiding medication errors A tidy, organised dispensary allows a pharmacy team to work together safely. Medications left lying around on the dispensary benches can become mixed up with patients’ medications. This can ultimately lead to serious consequences
“With so many brands now producing similar looking and sounding medications, it’s easy for an error to occur when putting away and picking out stock ” for patients who trust their pharmacy to only dispense items that they should be taking. Making sure that shelves are tidy and that items are clearly separated from each other also ensures that during the picking process it is easy for the person collecting the medicines to quickly select the item they need. Keep a near miss log One way to avoid a repeat of a medication error is to keep a ‘near miss’ log. The process of writing down an error, and the reasons for it occurring, can be a good way to identify how the error could be avoided again in the future. Near misses should be highlighted to the whole dispensary team and action should be taken to reduce the risk of the same error happening again (eg separating similar sounding drugs). The near miss log should be regularly
Fake prescriptions Pharmacists and their teams should always be vigilant to the risk that a prescription could be fake or amended without the prescriber’s consent. Be particularly wary of prescriptions for items prone to abuse, such as anxiolytics, painkillers or sleeping tablets. If you have concerns about the legality of a prescription, you should contact the prescriber in the first instance to confirm the details. The police may need to be involved if a prescription is identified as fake. High-risk medicines Looking through some of the recent MSO reports, it is interesting to note that medications that
chemistanddruggist.co.uk/update-plus
Module 1830 | Medication errors | 2 of 3
reviewed and broader lessons learned from why mistakes have happened. Creating an atmosphere in which everyone can be open about their mistakes is extremely important when trying to reduce the error rate in your pharmacy. We all learn from mistakes – whether these are our own or those of someone else. If you are the pharmacist, lead by example and highlight times when you have made errors. Talking to C+D in February, Royal Pharmaceutical Society president Martin Astbury admitted making two dispensing “crimes”, as part of his call for inadvertent dispensing errors by pharmacy professionals to be decriminalised (see Criminal sanctions, right). By addressing his own mistakes, he encouraged others to do the same.
The consequences of medication errors Patient harm The worst consequence of a medication error is that your patient will come to some sort of harm. The result could potentially be hospitalisation and, in some severe scenarios, patient death. Medications have the ability to change peoples’ lives for the better, but if used incorrectly or by the wrong person the consequences can be deadly. Criminal sanctions The Crown Prosecution Service (CPS) issued guidance in 2010 in relation to whether or not to prosecute a pharmacist for a dispensing error (tinyurl.com/medincidents-2). The guidance focused on the seriousness of
Medication errors CPD Reflect How are medication errors defined? What are the most common causes of errors? How can pharmacists reduce the risk of errors occurring? Plan This article defines what a medication error is, as well as information about their common causes and the steps pharmacists can take to avoid them. The consequences of errors and what to do if an error occurs are also discussed. Act • Review any medication errors that have occurred in your pharmacy. Think about how they could have been avoided and any changes in procedures or training that would prevent them occurring again • Make sure all members of staff involved in dispensing regularly revise their knowledge of the standard operating procedures – it is easy to become complacent or take short cuts when busy • Read the National Pharmacy Association’s (NPA) medication safety officer’s (MSO) report for October-December 2016 at tinyurl.com/medicationerrors1, which identifies the most recently reported medication errors and contains tips for minimising risks • Find out about reporting medication errors on the Pharmaceutical Services Negotiating Committee website at tinyurl.com/medicationerrors2 Evaluate Do you now know the most common causes of medication errors? Could you put into place procedures to prevent them occurring?
chemistanddruggist.co.uk/update-plus
the dispensing error and the outcome for the patient. In addition, it looked at the intent of the person who made the mistake and their previous dispensing error record. The recent prosecution of Northern Irish pharmacist Martin White for an inadvertent dispensing error (tinyurl.com/medincidents-3) – that was linked to a patient’s tragic death – is a stark reminder to all pharmacists of the risks associated with making medication errors. Despite a previously unblemished record, this one mistake cost Mr White his career. What is interesting about the Mr White case is that the same inadvertent error – dispensing propranolol for a prescription of prednisolone – was attributed to locum Elizabeth Lee in 2009. As with Mr White, Ms Lee received a suspended sentence.
What should you do when an error occurs? Pharmacy teams should review their SOPs regularly to identify why any errors have happened and how to prevent future mistakes happening again. However, often pharmacy teams do read the SOPs, but there is no check to ensure that they are following them correctly. It may therefore be worth observing members of the pharmacy team to see if they are adhering to the SOPs. If not, this is the perfect time to offer feedback. While in an ideal world dispensing errors would never occur, a number are inevitable in pharmacy practice. However, the suggestions in this module should help you and your team keep these to an absolute minimum – to the benefit of both patients and your staff.
Take the 5-minute test online 1. The number of prescription items dispensed per year has increased by 60% between 2005 and 2015. True or false
6. To reduce errors, medications should be picked using the dispensing label rather than the prescription. True or false
2. A close link has been reported between workrelated stress and medication errors. True or false
7. Insulin should be dispensed and then placed in a clear bag so the patient is easily able to verify that the brand is correct. True or false
3. Within community pharmacy, the reported dispensing error rate is between 3.5% and 4.5%. True or false 4. The most common dispensing errors involve incorrect dosage directions, drugs, strengths or forms. True or false 5. Misreading a prescription can lead to an incorrect item being selected or the mislabelling of an item. True or false
8. Calculations for prescriptions should be worked out in a quiet part of the dispensary on a fresh piece of paper. True or false 9. Keeping a near miss log can be one way of avoiding the repeat of a medication error. True or false 10. Creating an atmosphere where employees can be open about their mistakes is extremely important when trying to reduce error rates. True or false
Module 1830 | Medication errors | 3 of 3
