The (almost) last chance to avoid disaster

April 7, 2010

A pharmacist's most important job is to see that the right drug in the right strength with the right label reaches the right patients.

Key Points

By law and tradition, pharmacists are granted an almost exclusive right to oversee the prescription drug distribution network in the United States. Most of the time, we discharge our responsibility correctly.

Occasionally, however, we get it wrong. There may be an injured patient, an insurance claim, a malpractice lawsuit, and/or a complaint filed with the board of pharmacy. Whether any of this happens may depend upon luck.

Every time we have analyzed an error in a community or hospital pharmacy, we have found not one mistake but several, and seldom fewer than four. When we design a quality assurance workflow, we build into it risk-management techniques or best pharmacy practices that will prevent a mistake from occurring or that will allow us to recognize and correct that mistake before it reaches a patient.

The good news is that we need not prevent all the mistakes in a workflow leading to an error. Usually, we need only to discover one of these mistakes to prevent the error from reaching the patient. This is the difference between failure and success.

When an error occurs, several hands may have been involved in the failure to deliver the right drug to the right patient, but one person is ultimately responsible. The pharmacist's license gives him or her the right to dispense dangerous drugs, and with right goes responsibility for most medication errors.

A pharmacist I represented before a board of pharmacy on a medication-error complaint told the board, "Don't blame the technician. She may have made the mistake, but it was my job to keep any of her mistakes from getting to a patient. Any fault is always mine."

The final quality check

No matter what quality assurance plan the corporation or the owner of the pharmacy may put into effect for the pharmacy or the hospital, it is the individual pharmacist who has ultimate control of the final quality check on every prescription placed on the counter in front of him or her on its way to the patient.

Since responsibility lies with the pharmacist, the pharmacist has the right to insist on having the tools needed for the final quality check. A dedicated area should be set aside. It need not be large, but it should be roomy enough for the basket containing the filled prescriptions, receipts, stock bottles, and patient or prescription information.

The pharmacist should develop a list of items to check every time. The checklist might include the right patient, right drug, right strength, right directions, right doctor, and right number of refills. With C-II's, a recount check could be added. Other items might depend on the pharmacy and prescription type. For example, a dosage check of a child's prescription might be in order.

This area is also a good place to perform the prospective drug review. In one pharmacy chain, we added an extra terminal in this area, so the pharmacist could pull up the patient profile and review any conflicts the computer registered when the prescription was entered.

One additional suggestion – memorize the checklist and then put it in a drawer. The use of a checklist leads to the thought that the job is to check the boxes. It is better to learn the list, in order, through repetition. It's hard to ignore a developed habit, and it becomes difficult to skip a step practiced and learned in order. Every once in a while, test yourself and the rest of the pharmacists in the pharmacy; have each one go through the list while someone checks to be sure each person remembers correctly.

New tools coming on the market can help pharmacists with their final check. I recently reviewed Pass Rx, which uses chemical and visual analysis to verify the drug in the finished prescription against what the computer information said should be there, using bar-code scanning. The speed and accuracy of the product and its ability to reduce medication errors were impressive.

Whether your pharmacy is high tech or low tech, the pharmacist's final quality check is an important part of fulfilling your duty to "first do no harm."

These articles are not intended as legal advice and should not be used as such. When a legal question arises, the pharmacist should consult with an attorney familiar with pharmacy law in his or her state.

KEN BAKER is a pharmacist and an attorney. He consults in the areas of pharmacy error reduction and risk management. You can contact him at ken@kenbakerconsulting.com
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