Most tasks performed at a pharmacy are done by a person. A few tasks are automated, but still programmed by a person. As you know, people make mistakes. It is inevitable and it is true even when it comes to pharmacists and their staff.
CNBC reports that the third leading cause of death in America is medical errors that can include medication errors. In fact, the Center for Patient Safety reports 770,000 medication errors cause injury to patients each year.
This is an alarming number. As a physician, you do not want your practice or your patients to be a part of these statistics.
What exactly is a medication error?
Medication Errors Defined
Medication errors have been defined by the National Coordinating Council Medication Error Reporting and Prevention. They are any preventable event that could lead to misuse of a medicine or patient harm.
Medication errors can be related to poor professional practices, procedures and systems. They can happen during any process of filling a prescription, from product labeling, order communication, packaging, compounding, dispensing, education and use, to name a few.
There are many causes for medication errors that happen inside a pharmacy. Below are some of these reasons, with more detailed explanations of why they happen.
Error: Incorrect Entry of Prescription
Transcription mistakes accounts for 15 percent of all dispensing errors, according to a recent article in Pharmacy Times. Transcription errors happen because a person entering data makes a mistake and keys in the wrong information for the medicine prescribed.
For instance, they type “50mg” when they should have typed “5mg”. An error like this can be extremely harmful, possibly fatal, to a patient.
It can be hard to read your handwriting on a prescription. And sometimes, even your staff can make a data entry error on a prescription that is sent to a pharmacist. Rather than bother you, pharmacists will often try to make their best guess at what you want to prescribe.
In addition, it is easy for pharmacists to mistake drugs for one another when they are similar in spelling, abbreviations, dosage and appearance. Again, this is very dangerous for the patient.
Error: Lack of Patient Education
Patients rarely ask the pharmacist questions about their medications. They have already been waiting over an hour for their prescription to be filled. The last thing they want to do is prolong their visit to the pharmacy.
And because the pharmacists and his or her technicians are overloaded with orders, they don’t always engage the patient in conversation about the prescription.
An undercover investigation by the news show 20/20 revealed that 70 percent of the pharmacies they visited did not take the time to tell patients about potentially harmful interactions.
Patient go home with printed information stapled to the bag of their prescription. Those papers typically end up in the trash can without be viewed. Therefore, the patient receives no education on side effects, interactions or what to do in case of trouble.
They follow the orders on the bottle and hope for the best.
Patients do not realize just how many dangerous drug interactions there are. They trust you and the pharmacy to give them this information. If you are relying on the pharmacist to explain interactions to your patients, you will be disappointed. And your patients may suffer the consequences.
Error: Distractions
Pharmacists are constantly being interrupted while they are compounding and filling prescription orders. They may have a phone call come in from a doctor’s office. They may have a staff member ask a question. They may need to communicate with an insurance company.
Distractions such as these create potential for errors. They cause interference of a pharmacist’s focus. While pharmacists are great at multi-tasking, they are still susceptible to errors.
Error: Cross-Contamination
Cross-contamination can happen. People do not realize it, but medicines can be handled by pharmacy technicians and pharmacists that can pass germs to their medicines. While many pharmaceutical staff wear gloves, they do not change gloves often.
Germs and bacteria can travel a distance through sneezing and coughing. These germs can land on the preparation table where staff are working, where medicines are placed.
Cross-contamination can also happen when the preparation area is not cleaned properly in between compounding. This means some medicines can have traces of other medicines mixed in with them. For instance, your patients may receive their blood pressure medicine with traces of a controlled substance if the pharmacist didn’t clean the area where they compound.
Error: Giving Patient the Wrong Medicine
Believe it or not, pharmacists have given patients the prescriptions of other patients. This is easy to do when you are filling thousands of orders every day. The medicines don’t even have to be mislabeled for this to happen.
The staff reaches in the “S” box, gets out the supposed prescription for Mrs. T. Smith. Unfortunately, they gave her the prescription for Mrs. L. Smith. Not all patients pay close attention to their medicine. They expect the pharmacy to get it right.
They go home, take the wrong medication, and experience an adverse event.
Error: Packaging
Every medicine has a specific way to be packaged so they maintain effectiveness and safety for patients. When a medicine is packaged and stored incorrectly, it will not work properly.
When a medicine is not able to perform for the patient as it should, the patient could suffer. They may not receive the correct dose due to being stored in the wrong container or wrong temperature. They could even be at risk for consuming medicine that is rotten.
In conclusion, medication errors are going to happen. If prescription writing continues to grow and pharmacists continue to be overwhelmed, errors will exist.
One way to avoid all these errors is to use a system that involves prepackaged medication. These are designed to prevent errors found in working with a pharmacy. From labeling, storage, and temperatures, to safe packaging, prepackaged medication can help physicians ensure the safety of patients and reduce errors.