It’s been 20 years since the Institute of Medicine released its landmark To Err is Human report, but medication errors remain a serious problem in our health care system. Pharmacists are positioned to play a key role in preventing or catching errors that can occur at the various stages of the drug-use process: prescribing, dispensing, and administration. Here are some strategies that can help.
1. MINIMIZE CLUTTER
The pharmacy environment is often fast-paced and intense, with high prescription volume, insufficient staffing, and demanding patients. Keeping pharmacy counters clear and clutter free can be challenging, but it is an important part of reducing risk for dispensing errors, said Matthew Grissinger, RPh, director of error reporting programs at the Institute for Safe Medication Practices (ISMP) in Horsham, Pennsylvania. He advises pharmacies to use a basket system to keep different patients’ prescriptions and drugs separate, as well as to clear away the bottles from prescriptions that have been completed. Ideally, he said, pharmacists should take phone calls in a quiet, distraction-free area.
2. VERIFY ORDERS
For prescriptions called in by phone, it’s important to write down and then repeat the order to verify that it was heard correctly; ISMP recommends spelling drug names during read back.1
E-prescribing comes with its own pitfalls, according to Dixie Leikach, RPh, vice president of Catonsville and Paradise Professional Pharmacies in Catonsville, Maryland. Her pharmacy often deals with problems caused by improper use of the technology. For example, sometimes prescribers can’t find the correct drug strength or dosage form on the e-prescribing dropdown menu, so they select a similar drug from the list and then write the intended product in notes in other areas of the prescription, which can be missed during order entry. “We’ve learned over time that we have to read all the information and clarify if something really doesn’t make sense,” Leikach said.
3. USE BARCODES
Scanning barcodes plays an important role in checking that the correct drug, dosage form, and strength has been selected, Grissinger said, ensuring that the most common dispensing errors are avoided. But he cautions that in the retail environ- ment, this will only work if orders are entered in the system before selecting the drug bottle; if pharmacists pull the wrong drug off the shelf and enter its NDC number, barcoding will not catch that error because the incorrect barcode will appear on the prescription label.
At Boulder Community Health (BCH) in Boulder, Colorado, where Christopher Zielenski, PharmD, is pharmacy clinical coordinator, the use of barcoding throughout the system, from dispensing through administration, has resulted in a huge reduction in errors. Since they began requiring barcode scanning for medications being placed in automatic dispensing cabinets, the rate of mistakes in filling medications has been reduced to nearly zero, he reported.
4. BE AWARE OF LOOK-ALIKE SOUND-ALIKE (LASA) DRUGS
ISMP maintains a long list of drugs with similar names that may be confused, which it recommends printing in bolded tall man (uppercase) letters (eg buPROPion/busPIRone).2 It is imperative for pharmacists to stay informed about what those drugs are, experts said. Grissinger advised that every pharmacy choose 5 common LASA pairs and develop strategies to avoid errors with them, such as separating them. If drugs are separated, he cautioned, pharmacists and techs need to know where they are located.
Leikach said that LASA lists grow as more drugs become available in generic formulations. She gave risperidone and ropinirole as an example. “When those were brand names they weren’t a problem, but once they both went generic and they’re both available in the same strength... and they’re sitting next to each other on the shelf, all of a sudden you’ve got a huge potential for pretty severe med errors and adverse drug effects.”
5. HAVE A SECOND PAIR OF EYES CHECK PRESCRIPTIONS
One way to prevent human error is by involving a second human—a pharmacist or technician (as permitted by state law)—in the dispensing process. “If I’m the one taking the prescription and entering it, then I’m not pulling the drug and counting it, because I know I have to final check it,” Leikach said. “Someone else, a tech or another pharmacist, will look at it.... We check each other.” When she worked in environments where there was no one else there to check, she would walk away from prescriptions once she’d reached a certain point in the dispensing process, so that she could come back with “a fresh set of eyes.”
Grissinger cautioned that final checks should always include verification of the original order entry, whether by keeping the paper prescription with the label and medicine bottle until completion or by pulling up the scanned prescription on the computer screen.
1. Cohen M, Hanson A, Shah N. Top medication errors reported to ISMP in 2019. Webinar presentation. December 18, 2019. https://www.ismp.org/sites/default/files/attachments/2019-12/Top%20Errors%20handouts.pdf. Accessed March 6, 2020.
2. List of Confused Drug Names. Institute for Safe Medication Practices. https://www.ismp.org/recommendations/confused-drug-names-list. Published February 28, 2019.
3. Hanifin R, Zielenski C. Reducing medication error through a collaborative committee structure: an effort to implement change in a community-based health system. Qual Manag Health Car. 2020;29(1):40-45. doi: 10.1097/QMH.0000000000000240.