Reducing your risk: Medication errors – The value of habit


A safe workflow that's ingrained in pharmacists can do much to reduce the likelihood of drug errors.

It was the simplest of errors – a prescription for an ophthalmic drop was filled with an otic drop of the same brand. This mistake is so common, that over the past several years it has consistently represented 2% of all Pharmacists Mutual Insurance Co.’s claims against pharmacies involving a mechanical error.

I received a telephone call from a pharmacist who told me that he had just received a phone call from a young mother who was outraged. She had placed a drop of what was supposed to be eye drops in her four-year-old child’s eye. He had screamed in pain because the medication was not the ophthalmic, but otic, form of the drug. As typical with this type of ophthalmic/otic claims, there was a lot of pain but no permanent damage – except for the reputation of the pharmacy in the eyes of the woman, who was determined to tell everyone whom she knew about the incident.

When a professional pharmacy claim is received at Pharmacists Mutual, after all initial questions are answered and the pharmacist has made sure that all appropriate steps have been taken to address the immediate needs of the patient, the next step is to investigate how the incident occurred. How could such a simple, common mistake be made without it being caught by the pharmacist before it reached the patient?

Checking the written prescription ensures that the mistake was a pharmacy, and not a prescriber, error. The prescription was clearly written and was for the ophthalmic form of the medication. One other possibility was that the mistake could have been made when the technician entered the information into the computer. But a check of the label and the computer records showed all information had been entered correctly. The mistake, in this case, was a filling miscue. The wrong form of the medication – the otic version – had been pulled from the shelf and used to fill the prescription when the prescription clearly indicated that the ophthalmic one was intended.

Once an investigation identifies how and where a mistake has been made, it is then customary to discuss techniques or best practices with pharmacy staffers that they can put into place to avert such an error from happening again. We do not at this time suggest they try to solve all problems that could possibly occur in the future – only this one. Often the pharmacist in charge would ask each person involved in the claim to be a part of the solution, by asking that each suggest one or more simple, preventive steps, or pharmacy best practices, to be made a part of the pharmacy workflow.

In the case of this otic/ophthalmic switch, there were several suggestions made by the pharmacist and technician involved. The most obvious was performing an NDC check on each prescription. A simple NDC check would have certainly caught this quality-related event (QRE) before it reached the patient.

It is instructive that when we asked the person who filled the prescription, pulled the wrong product from the shelf, applied the label, and placed the finished prescription in the bag if he ever did an NDC check, the answer was “yes.” He was emphatic: “I do an NDC check on every prescription!”

Every time I have asked that question, I have usually received the same answer: “Always, on every prescription.” Obviously such a check was not done in the instances where the drug errors occurred, but the health professionals were sure, nonetheless. Our minds are wonderfully complex mechanisms, but sometimes they can fool us. We all believe we always do an NDC check, but experience suggests that the best of us do it considerably less than “always.”

The exception – the one who does it every time – is the one who has “no choice” but to do it every time. The robotic prescription filling machine does it each time, because that was how it was programmed. Other mistakes may be made and robots sometimes create their own problems, but forgetting to do an NDC check is not one of them. The machine has no choice.

We can also train ourselves and our staff to have “no choice.” With a kind of programming (I call it Quality Habits), we can be trained to not have a choice. A habit can be thought of as programming of the mind. If we can develop a routine in filling prescriptions such that our mind will not let us skip one of the programmed steps, then we can reach a point where we do a particular step every (or almost every) time.

When our children are learning to drive, we want to teach them to fasten the seat belt every time. If we can instill in them the habit of buckling the seat belt before turning the key, they will do it even when we are not there to insist. We teach them the routine: buckle seat belt, then start car. Eventually (we hope) these steps will become so routine that they cannot start the car without the brain reacting: “Wait – you forgot something!”

A routine set of steps (a work flow) used each time in filling prescriptions can have a similar effect. Had the pharmacy with the otic/ophthalmic mix-up used a workflow containing a series of steps that are taken each time in the same order, it could have developed quality habits making the error less likely.

With established quality habits, including an NDC check or a bar-code scan, it is likely the pharmacy could have avoided delivering the wrong drug to the young patient. The actions used to establish quality habits must be done every time in the same order and become so routine that the technician no longer has to think about each step. The steps become programmed into the process. Once a quality habit is formed, it becomes difficult to skip a step, such as the NDC check. The human mind is truly amazing.

The author is a pharmacist and a lawyer who consults in areas in which he has worked for more than 30 years. He can be reached at

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