a presentation on the common dispensing error encountered in a pharmacy and the role of pharmacy technicians in curbing or reducing the rate of these common errors
TIME FOR ACTION: MAY 2024 Securing A Strong Nursing Workforce for North Carolina
COMMON ERRORS IN DISPENSING by Mrs omorodion 3.pptx
1. PRESENTER: PHARM TECH MRS OMORODION JUDITH
MODERATOR: PHARM TECH MRS EBEHI JOVI
PHARMACY DEPARTMENT, UNIVERSITY OF BENIN TEACHING HOSPITAL
2. OUTLINES
INTRODUCTION
EPIDEMOLOGY
TYPES OF DISPENSING ERROR
COMMON CAUSES OF DISPENSING ERROR
POSSIBLE SOLUTIONS TO THE COMMON CAUSES OF DISPENSING ERROR
ERRORS RELATED TO INFORMATION ABOUT THE DRUG
TASK TO REDUCE DISPENSING ERRORS
CONCLUSION
REFERENCE
3. INTRODUCTION
Dispensing refers to the process of preparing and giving medicine to a named
person on the basis of a prescription.
It involves the correct interpretation of the wishes of the prescriber and the
accurate preparation and labelling of medicine for use by the patient.
GSKPRO
Dispensing is one of the vital elements of the rational use of drugs
4. INTRODUCTION…
Good dispensing practice involves:
the delivery of the correct medicine
to the right patient
In the required dosage and quantity
In the package that maintains acceptable quality
for the specified period
with clear medicine information for appropriate counselling
5. INTRODUCTION…
Error refers to a wrong action attributable to bad judgment or ignorance or
inattention
A dispensing error refers to an inconsistency between the dispensing of a
medication to a patient against the medication prescribed
This error can lead to ineffective and sometimes unwanted pharmaceutical
outcomes
They can be harmful or even fatal to patients
6. INTRODUCTION…
Medication error is not the same as dispensing error
medication error can be defined as any preventable event that may cause or lead to
inappropriate medication use or patient harm while the medication is in the control of the
health care professional or patient.
It cuts involves prescribing error, dispensing error, preparation error, administration error and
monitoring error
Therefor dispensing error is a subset of medication error
7. EPIDEMIOLOGY
Medication errors are the leading cause of mortality in the world
About 21% of all medication errors occurred as a result of dispensing errors in the
United States
98.3% accuracy in dispensing medications
Therefore, 1.7% inaccuracy rate
over 3 billion medications dispensed per year
4 errors per day 250 prescriptions per day
over 51 million dispensing error per year
8. EPIDEMIOLOGY…
The National Reporting and Learning System (NRLS) collects incidents from community pharmacy
practice in England and Wales . Recent reviews of 14,704 incidents reported to the NRLS between
2005 and 2010 found that the most commonly reported errors in community pharmacy were:
Wrong dose/strength (30.3%)
Wrong medicine (28%)
Wrong formulation (12%)
Wrong quantity (9%)
The vast majority of errors (92%, [n=13,573]) did not result in any harm and few (< 1% [n=29])
resulted in severe harm or death
9. TYPES OF DISPENSING ERROR
COMMISSION/ OMMISSION
MISTAKE / SLIP
POTENTIAL / ACTUAL
10. Types of dispensing error …
OMISSION:
FAILURE TO Dispense a drug that is among a prescription
COMMISION:
miscalculation of a dose
Dispensing the incorrect medication, dosage strength or form
MISTAKE:
Doing things intentionally but actions are incorrect because of a knowledge or
judgement deficit eg dispensing a dose prescribed that is above the maximum
safety limit
SLIP:
To do things unintentionally incorrect because of an attention deficit
11. COMMON CAUSES OF DISPENSING ERROR
Work environment
Work load
Distractions
Work area
Knowledge deficit
Use of out dated reference materials
No continuous professional development
Insufficient knowledge about medication
12. Possible solutions to the common causes of
dispensing error
Improving workload
Ensure adequate staffing levels
Eliminate dispensing time limits (dispensing must not always be done in a haste)
ways we can improve work load include
1. Dispensing within the recommended daily limit (< 100 prescription per work shift)
2. Take rest breaks after every 3 hours of work
13. Possible solutions to the common causes
of dispensing error
Following the proper dispensing guideline which include
Ensure the prescription is correct and valid
Ensure correct entry of the prescription
Patient demographics, hospital number, accurate quantity/ strength of drugs to be
dispensed
Beware of look-alike, sound-alike drugs
Be Careful with zeroes and abbreviations
Organize the work place
Take time to store drugs properly
Using FIFO/FEFO
Drugs of different dosage forms or rout of administration should not be stored together
e.g benzyl benzoate should not be stored together with vitamin c syrup
14. Possible solutions to the common causes
of dispensing error
Dispensing error can be reduced in the work area by
clutter( return used containers immediately)
Ensure adequate work space
Store products with label facing forward
Adequate lighting
Label the shelves
Separate drugs by route of administration
Separate sound-alike/look-alike drugs
15. Errors related to information about the
drug
Misleading or wrong references
Ensure to site a trusted, well-known and up to date reference material always
Ambiguity in handwritten and typed documents
Avoid assuming anything for the prescriber always clarify any ambiguity in a prescription before
dispensing
Computerized prescribing :
improves communication and reduces some types of error (error due to non legible handwriting )
However this technology may have its own pitfalls most common ones are
Lower case L may look like the numeral 1(one)
Letter o may look like numeral 0(zero)
Wrong patient or wrong drug chosen from the list
16. Errors related to information about the
drug
Wrong patient errors: when a wrong drug is prescribed for a patient or when a
patients name is wrongly written on another patients prescription
This error can be detected and corrected by asking the patient about her diagnosis(if
he/she knows) or the chief complaint
The medications should address the diagnosed illness and(or) its accompanying
symptoms
Errors in dosage
Mathematical errors and decimal point misplacement are common causes of errors
Example mcg and mg
17. Task to reduce dispensing errors
Independent double checks before dispensing(ADC System)
To minimise dispensing error one individual should not access, dispense a prescription and counsel the
same patient
This division of labour is very effective in the prevention of dispensing error because it offers a third eye
view to every prescription that passes though the pharmacy
Original prescription order and the medication container(dispensing envelope) should be kept together
throughout the dispensing process
A pharmacist must check all of technician’s work
Up to 83% of dispensing errors can be discovered during patient counselling and corrected before the
patient collects his or he drugs
18. CONCLUSION
Dispensing error, an error that can cost a life can be prevented by practicing good
dispensing guidelines, keeping a conducive work environment, adhering to
independent double check and avoiding unnecessary distractions wile dispensing
19. References
Royal Pharmaceutical Society. The RPS advanced pharmacy framework. 2013. Available at:
https://www.rpharms.com/Portals/0/RPS%20document%20library/Open%20access/Frameworks/RPS%20
Advanced%20Pharmacy%20Framework.pdf
NHS Improvement. The National Reporting and Learning System. 2020. Available at:
https://report.nrls.nhs.uk/nrlsreporting/Default.aspx
https://www.vocabulary.com/dictionary/error
Flynn EA, Barker KN, Carnahan BJ. National observational study of prescription dispensing accuracy and
safety in 50 pharmacies. J Am Pharm Assoc. 2003;43(2):191–200.
