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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.
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.
6. DESIGN EFFECTIVE WARNING SYSTEMS
Various alert strategies can be helpful, but human nature is to overlook the familiar. That’s why Leikach moves around shelf talkers alerting staff about LASA drugs so they continue to catch the attention of staff members. She has also requested that the pharmacy software system change some alerts to hard stops, so that the pharmacist or technician is required stop, read the alert, and type a response-thus ensuring that they pay attention.
7. INVOLVE THE PATIENT
Patients are their own last line of defense when it comes to medication errors, and investing a minute or 2 in speaking to them can reap huge dividends in catching medication errors. Grissinger advises asking the patient when they pick up the prescription: “Open the bag; is this what you were expecting? Look at the label, look at the name of the drug, look inside the bottle if it’s a refill to make sure it’s what you got last time.”
Basic counseling can help ensure that patients understand what their prescription is for and how to take it properly; it sometimes helps catch errors as well. Leikach recalled situations where she could tell that her explanation did not make sense to the patients. “They said, ‘That’s not why I went to the doctor, that’s not what he told me!’” This enabled her to catch medication errors made by the prescriber or the dispensing pharmacist, she said.
Speaking to patients is also valuable in obtaining an accurate medication reconciliation, Zielenski noted, which is why BCH has instituted training in active listening for staff involved in medication reconciliation.
8. TRUST YOUR GUT
"Pharmacists need to recognize their role to the patient,” Leikach said. “When you receive a prescription-especially if you get to know your patients-then if something doesn’t make sense don’t just let it go.” Question the patient and call prescribers to verify, she advised, and if necessary, dig deeper to obtain clarification on why something was prescribed as it was and whether it was a mistake. After enough occasions of being thanked by prescribers for catching their errors, Leikach realized that “you really do need to push when you feel that something isn’t right,” she said.
9. BE PROACTIVE
“Let’s not keep waiting for things to go wrong and fix them,” Grissinger said. Experienced pharmacists can sense when things are not going right and should address those concerns, he said. “Otherwise something’s going to go wrong and the pharmacist is going to get blamed for that when we saw it coming a mile away.”
ISMP has free self-assessment tools that pharmacists in different practice settings can use to evaluate how well they are maintaining patient safety. Its Medication Safety Self Assessment® for Community/Ambulatory. Pharmacy includes over 200 items in 10 elements important for safe medication use.
Sometimes, Zielenski said, simple changes can have a big impact. For example, BCH started stocking batteries on the floors after pharmacists realized that barcode medication administration rates were dropping due to scanner batteries running out. Similarly, BCH includes dosing and administration instructions with emergency kits.
“Those types of tools can be implemented anywhere,” he noted. “Frontline staff can develop them; it doesn’t have to come from a manager.”
10. TRACK MEDICATION ERRORS
“I believe in reporting safety events-which are classified as near-misses and errors-even if they are your own, to allow a big picture to develop so we can identify trends at the system level and then address those issues and encourage peer-to-peer feedback,” said Zielenski. He recently published an article describing how BCH developed several interdisciplinary committees that used medication safety events reported through its voluntary electronic safety event reporting system to perform continuous quality improvement throughout the hospital.3 Over the course of 3 years, there was a significant drop in rates of medication errors and concomitant increase in the rate of near misses, while reporting rates remained the same.
Open discussion of medication errors is most helpful when an institution has a just culture perspective, Zielenski added. “As soon as it becomes part of a normal conversation, I think that’s where you really start to gain traction on reducing medication errors,” he said.
1. Cohen M, Hanson A, Shah N. Top medication errors reported to ISMP in 2019. Webinar presentation. December 18, 2019.
. 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.