How to Prevent Medication Errors

Drug Topics JournalDrug Topics February 2019
Volume 163
Issue 2

Pharmacists must cultivate a culture of safety, training to protect patients.

Doctors on Computer

First, do no harm. We’ve all heard these words from the Hippocratic Oath. But from the sounds of it, we might not be listening very well. A shocking 2016 report out of Johns Hopkins indicates that medical error is now the third leading cause of death in the United States. While all of these fatalities are not medication-related errors, many are.

Medication errors can happen in any setting, but I am especially sensitive to the challenge of preventing errors in a retail pharmacy where there are so many competing priorities and constant distractions. My advice, therefore, is especially aimed at my brothers and sisters on the bench.

Create a Culture of Safety

Preventing errors has to become the very flavor and language of your pharmacy. When you travel, you learn about different cultures by immersing yourself in their language, food, customs, and style. Visitors to your pharmacy should likewise get a sense that “safety” is your custom, the way you live and move. You do this by talking about it frequently, sharing examples, telling stories, and being a champion of error-prevention yourself.

Don’t Skimp on Training

believe the training programs in most of our organizations are inadequate for the demands of a busy, distracting retail pharmacy. Sure, we expect our personnel to have a baseline drug knowledge. But where we fall short are the computer-training, problem-solving, communication-techniques, and people-skills needed to efficiently work together as a team. Untrained people get flustered and then make mistakes. Well-trained people work more efficiently. Good training brings all the parts together. And this requires an investment in great trainers and training programs.

Require Order

I urge you to have a zero-tolerance policy for chaos in the pharmacy. The mantra I communicate frequently to my team is: “Busy is good, chaos is not.”
Chaos is usually the result of one or more good people making one or more bad choices.
For example, we might cut corners to try and speed things up to an unsafe pace. Baskets in the work flow might get disorganized. Patients might be promised unrealistic timelines, thus putting inappropriate pressure on the team. Someone might get flustered, distracted, or upset. You need a leader, ideally the pharmacist, to exude a calming influence and to insist on maintaining decency and order in the work flow steps.

Get in the Zone

I tell my pharmacists to picture themselves in a courtroom every time they verify a prescription, trying to explain to a jury why they allowed that prescription to go out. A scary thought-but we need sobering reminders of just how serious our job is.

Take a breath. Read the label carefully. Think. You must train yourself to look for all of the possible errors that may be in front of you. Is this a commonly confused drug or dosage form? Does the dosing make sense? Does the prescription seem reasonable for this patient given their age, gender, and history? There’s simply no checklist that will replace the importance of getting your head in the game. Every time. Every single prescription.

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