Top 5 Tips for Preventing Medication Errors

September 6, 2018

Jason Poquette is the director for outpatient pharmacy services at Saint Vincent Hospital in Worcester, Mass., and an APPE preceptor for the Massachusetts College of Pharmacy. Contact him at Jason.pharmacist@gmail.com.

Stopping medication errors in a busy pharmacy isn't an easy fix, but steps must be taken to lessen a serious problem.

Primum non nocere. First, do no harm. We’ve all heard these words from the famous 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 U.S., or 250,000 deaths per year. While all of these fatalities are not medication-related, many of them are.

While medication errors can happen in any setting, 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 on how to prevent medication errors is, therefore, especially aimed at my brothers and sisters on the bench.

Here are my 5 tips to preventing prescription errors:

1. 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 frequently about it, sharing examples, telling stories, and being a champion of error-prevention yourself.

2. Don’t Skimp on Training

I 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 in the pharmacy. 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.

3. There Is No “One” Cause for All Errors

We all know that there are dozens of contributing factors to errors in the pharmacy.

For example, drug names that look alike or sound-alike could be misread. Directions can be wrong or incorrectly transcribed. Sloppy handwriting. A serious allergy or drug-interaction could be missed. A person might pick up the wrong patient’s medication. The wrong tablets could have been put in the bottle. A distracted technician or pharmacist rushed through a step and missed a mistake. Inadequate staffing or technology. Typically, more than one contributing factor is involved in any error that makes it all the way to a patient, a phenomenon referred to as “The Swiss Cheese Model.”

4. Order in the court!

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 workflow get disorganized. Patients are promised unrealistic timelines, thus putting inappropriate pressure on the team. Someone gets 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 workflow steps.

5. Get in the Zone

Learn to focus their attention on catching errors and block out distractions. 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, history? There’s simply no checklist that will replace the importance of getting your head in the game. Every time. Every single prescription.