How risky is your pharmacy?


NSW PDL Director Curtis Ruhnau takes a look at some of the more common areas of potential risk that PDL regularly sees.

Patient profile and prescription intake

Patient profile and prescription intake are the first contact patients have with us. They are therefore our first chances to get it right or wrong.

Here are a couple of short case studies:

  • A husband and wife both have a first name starting with same letter. A prescription was dispensed under one spouse’s name and taken by the other who didn’t recognise the difference due to generic packaging. Flagging multiple patients at the point of script intake can identify these issues for the dispensing pharmacist or technician.
  • Two patients with same names both have repeats kept at the pharmacy. One patient phones requesting “pills for mood” but quetiapine is dispensed instead of the SSRI. Developing a system to identify multiple patients to ensure that all staff, including locums and technicians are aware of patients with the same names, can reduce the chance of incorrectly labelling an item for a partner or other family member. Consider flagging a note on the patient profile within the dispensing system identifying two patients with the same name.

Prescription processing

Manual prescription data entry can lead to errors. Technology such as barcodes and QR codes can significantly reduce prescription input errors, although they are not perfect.

If there is any doubt don’t guess what is prescribed, don’t rely on the patient knowing what has been prescribed and don’t rely on past dispensing history. Instead always check with the prescriber.

Don’t allow yourself to be hurried in your work as this may compromise your patient’s health and your career. Input errors account for a significant proportion of dispensing errors reported to PDL.

Other common errors while processing prescriptions include Wrong Drug and Wrong Strength selections. The following lists are taken from our Notification of Incident data and include some drugs for which a mistake could be disastrous.

Most common ‘Wrong Drug’ dispensing

  1. Cephalexin
  2. Atorvastatin
  3. Coversyl
  4. Verapamil SR
  5. Diltiazem SR
  6. Spironolactone
  7. Amoxycillin
  8. Ciloxan
  9. Amlodipine
  10. Coumadin

Most common ‘Wrong Strength’ dispensing

  1. Methadone
  2. Prednisone/olone
  3. Janumet
  4. Thyroxine
  5. Digoxin
  6. Sertraline
  7. Rosuvastatin
  8. Oxycodone (incl Targin)
  9. Amoxycillin/Clavulanate
  10. Sifrol

Scanning prevents errors

If scanning had been undertaken the following common errors could have been prevented dispensing:

  • Coversyl 5mg instead of Coumadin 5mg due to similar packaging and location;
  • Pantoprazole 20mg instead of paroxetine 20mg due to similar name and location; and
  • Fluconazole instead of levonorgestrel due to similar corporate packaging, location and schedule.

Appropriate use of scanners could also prevent errors in situations such as:

  • multiple packs supplied, yet only one pack scanned;
  • corporate packaging of medicines leading to confusion between strengths;
  • special orders whereby the item has been dispensed and paid for, thereby preventing scanning of stock when received (a solution may be not to process or charge until the stock is on hand);
  • non-standard quantities (eg. a broken box – remember to scan original before repacking into plain box); and
  • change of brand after dispensing, yet no secondary scan which leads to the incorrect product supplied.

* This article by NSW PDL Director Curtis Ruhnau is based on an excerpt of a presentation that he will make at the Pharmacy Connect conference in Sydney on 9-10 September.

Come and hear the rest of the presentation that identifies how you can minimise risk of error in your pharmacy. 

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