9/13/2016
“Medication Dispensing Incidents: From
root cause to prevention”
Rony Foumia, RPH
Objectives
1.
Explain the root causes for medication dispensing incidents in the
community pharmacy setting.
2.
Explain how to make systematic changes to lessen the likelihood
of medication dispensing errors from occurring.
3.
Discuss how to appropriately handle medication dispensing
incidents when they occur.
Total Number of Retail Prescription Drugs Filled at Pharmacies
View Table in New Window
Total number of prescriptions filled at
community pharmacy settings 2014
Total number in the United States
1. California
4,002,661,750
445,835,829
2. New York
3. Florida
4. Texas
5. Ohio
6. Pennsylvania
255,645,810
248,850,279
228,035,987
184,814,413
183,237,833
7. Illinois
8. Michigan
156,296,507
130,727,767
Source: IMS Health incorporated: Special Data Request 2015
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Future projections
Michigan 2014 Total Number of Prescriptions
130,000,000 prescriptions filled in Michigan in 2014
x 99.999% accuracy would be how many
dispensing incidents per year in Michigan?
 Yearly it would be 130,000 incidents
 Monthly it would be 10,833 incidents
 Daily it would be 361 incidents
What is the definition of a dispensing
incident?
 Within the Center for Drug Evaluation and Research (CDER) which is part of the
Food and Drug Administration (FDA), the DIVISION OF MEDICATION ERROR and
PREVENTION and ANALYSIS (DMEPA) defines a Medication error as….
"any preventable event that may cause or lead to inappropriate medication use or
patient harm while the medication is in the control of the health care professional,
patient, or consumer. Such events may be related to professional practice, health
care products, procedures, and systems, including prescribing; order
communication; product labeling, packaging, and nomenclature; compounding;
dispensing; distribution; administration; education; monitoring; and use."
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Prevalence of Medication Errors in the
Community Pharmacy Practice
2006 Institute of Medicine (IOM) report “Preventing
Medication Errors” estimated one clinically significant error
occurs for every 962 prescriptions filled in the community
pharmacy setting
(Aspen P,Wolcott JA, Bootman JL et al. Preventing Medication errors:Quality Chasm series. Washington, DC: The
National Academies Press;2006)
Who makes mistakes?
 Any health professional that tells you that they have never made a
mistake or will never make a mistake is misinformed
 WE ALL MAKE MISTAKES!
 What we need to answer is…
Why it happened
How it happened – Root Cause
What did you learn from it
How are you going to PREVENT IT from happening again
Who is responsible for incidents?
When a dispensing incident occurs, something in the
“SYSTEM” along the drug delivery pathway went wrong
We ALL play a part in PREVENTING QUALITY RELATED EVENTS
from happening
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Challenges in our industry:
Similar looking drug containers
Challenges in our industry: Similar
looking drug containers
Challenges in our industry: Similar looking drug
containers – TML (Tall Man Lettering) – Lettering
used to distinguish similar drug names
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Challenges in our industry: Similar
looking drug containers
Challenges in our industry: Similar
looking drug containers
Challenges in our industry:
Sound alike/look alike drug names
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Challenges in our industry: Sound
alike/look alike drug names
 Actos/Actonel
 Adderall/Inderal
 Advair/Advicor
 Alprazolam/Lorazepam
 Alticor/Advicor
 Navane/Norvasc
 Celebrex/Celexa
 Zyprexa/Zyrtec
•
•
•
•
•
•
•
•
•
Cetrizine/Setraline
Chlordiazepoxide/Chlorpormazine
Clomipramine/Clomiphene
Clonidine/Clonazepam/Klonopin
Clozaril/Colazal
Diabeta/Zebeta
Duloxetine/Fluoxetine
Fiorinal/Fioricet
Flovent/Flonase
“ISMP’s list of confused drug names” (Go to
ISMP.com for complete list)
Challenges in our industry: Sound
alike/look alike drug names
 Foltx/Folex
 Glipizide/Glyburide
 Guanfacine/Guaifenesin
 Humalog/Humulin
 Hydralazine/Hydroxyzine
 Intuniv/Invega
 Januvia/Janumet
 Keflex/Keppra
•
•
•
•
•
•
•
•
•
Keflex/Keppra
Toradol/Tramadol
Trazadone/Tramadol
Lamisil/Lamictal
Lamotrigine/Lamivudine
Levofloxacin/Levetiracetam
Metolazone/Methimazole
Micronase/Microzide
Midrin/Midodrine
“ISMP’s list of confused drug names” (Go to
ISMP.com for complete drug list)
Challenges in our industry:
Handwriting
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Challenges in our industry: Handwriting
What is this medication?
Challenges in our industry: Handwriting
What is this medication?
Challenges in our industry: Handwriting
What could be the issue with
this prescription?
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Challenges in our industry: Handwriting
What is this medication?
Challenges in our industry: Handwriting
What is this medication?
Challenges in our industry: Handwriting
 NEVER assume!
 If you are not 100% sure, call the prescriber.
 Ask the patient questions. They can provide you with valuable
information. “Do you know why the doctor gave you this
medication?”
 Look at the patient history.
 Get a second opinion from a colleague.
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Challenges in our industry: Handwriting
R 338.479b Non-controlled prescriptions
 A prescriber shall not prescribe more than either of the following
on a single prescription:
For a prescription prescribed in handwritten form, up to 4
prescription drug orders.
For a prescription prescribed on a computer-generated form
or a preprinted list or produced on a personal computer or
typewriter, up to 6 prescription drug orders.
Challenges in our industry:
Pharmacy Calculation Errors
Challenges in our industry: Calculation
errors
This medication is often written with two different units
I.e. give 7.5mg once daily or give 0.5 ml once daily
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Challenges in our industry: Calculation
errors
Challenges in our industry: Calculation
errors
Watch for different concentrations: i.e 10mg/ml and 2mg/5ml
When to use and when not to use 0’s
Careful use of decimal points to avoid ambiguity:
1. Avoiding unnecessary decimal points if the number is
GREATER THAN 1: a prescription will be written as 5 mL
instead of 5.0 mL to avoid possible misinterpretation of
5.0 as 50.
2. Always using zero prefix decimals if the number is LESS
THAN 1: e.g. 0.5 instead of .5 to avoid misinterpretation
of .5 as 5.
3. Avoiding trailing zeroes on decimals: e.g. 0.5 instead of
.50 or 0.50 to avoid misinterpretation of .50 as 50.
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Challenges in our industry:
Abbreviation examples
Challenges in our industry: E-Scripts
Have E-Scripts (Electronic Prescriptions) eliminated all
hand written errors?
While e-scripts have decreased the likelihood of
dispensing errors due to legibility issues, they have
introduced a new set of possible errors
Challenges in our industry: E-Scripts
 Data entry into the E-script service
Selection of incorrect medication or patient
Transmittal to the incorrect pharmacy
 Notes added at the bottom of the E-Script that differ from
the sig code
 Doctor offices sending patients in quickly and
communication around wait times
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Are all dispensing incidents the same?
High Risk Medications:
 Opioids
 Insulin
 Anticoagulants
 Etc
Higher risk patients:
 Very young
 Elderly
Each dispensing incident must be treated with the same attention when
addressing the patient involved as the patient does not have the same
knowledge base as you
Challenges in our industry: DUR errors
 Allergies (i.e. Penicillin, sulfa etc)
 Therapy duplication errors (Lopressor and Atenolol
dispensed from two different prescribers)
 Expiration dates
Challenges in our industry: Increased
skill sets of a community pharmacist
 The profession of pharmacy has evolved and continues
to change at a fast rate
 Medication Therapy Management
 Immunizations
 Point of Care Testing
 Free healthcare advice
 Ease of access
 Reimbursement rate changes
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The workflow process – Where can
errors happen?
Drop
off/Data
Entry
Production
Pharmacist
Final Check
Point of
Sale
Workflow: Drop off/Data entry
Drop
off/Data
entry
Production
Pharmacist
Final Check
Point of
Sale
Workflow: Drop off/Data Entry
 Knowledgeable and experienced staff
 Historically, data entry is the origination of a large % of pharmacy errors
 Accurate patient information collection – Make sure the patient name is
clearly written WITH a DOB
 Allergies
 Address with UPDATED phone number
 Demand attention to DETAIL
 Watch for calculation errors
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Oral Prescription orders
For ALL oral prescriptions,
 ALWAYS REPEAT BACK what was said
 ASK ADDITIONAL questions if needed!
 Spell drug names back if needed
 Document who you spoke to
Workflow - Production
Drop
off/Data
Entry
Production
Pharmacist
Final Check
Point of
Sale
Workflow - Production
Make sure you grab the correct medication
 Utilize NDC’s
 Utilize current technology available to make sure the correct medication was
selected
 Utilizing shelf labels and dividers around high alert medications (sound alike/look
alike bottles) decreases the chance of errors happening
 Prescriptions that require a large number of units, be aware that ALL bottles
grabbed are the SAME
 Keep the counter NEAT and CLEAN and free of clutter
 Everything can be done right but be cautious of switched labels. Always
match what is in the bottle to the label
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Workflow - Production
Maintaining a clean and neat work environment will minimize the
chance of errors happening
Workflow - Final Verification
Drop
off/Data
Entry
Production
Pharmacist
Final Check
Point of
Sale
Workflow - Final Verification
 Take your time – take breaks, eat and maintain focus
 If you get interrupted, START OVER
 Follow a process that works for you and keep using it and REFINING IT
 Minimize distractions
 DOUBLE check your work
 Use of technology can help decrease errors
 It’s OK TO TAKE A BREAK, take a deep breath and rest
 DUR (Drug Utilization Review) - Duplicate therapy, allergies, increase in
dose etc
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Workflow - Point of Sale/Pick-up
Drop off/Data
Entry
Production
Pharmacist
Final Check
Point of Sale
Workflow - Point of Sale/Pick-up
 Patients with very similar names and dates of birth may lead to dispensing
errors
 Use second patient identifier in addition to the name. I.e. Jane Doe, Address
1234 Strawberry Cr. Or Jane Doe DOB 1-15
 Patient counseling
 Be aware of “Jr” or ”Sr” etc
 Accurate data collection at drop off and entry are crucial
 Pharmacist COUNSELING is a CRUCIAL step in educating patients about
their medication AND a CRUCIAL step in PREVENTING ERRORS!
Training: Technicians
 Senate Bill 92 – Public Act 285
 Effective December 22nd 2014
 Enforcement October 1st, 2015
 An individual that does any of the following needs to be licensed as a technician
in the State of Michigan:
1.
Assisting in the dispensing process
2.
Handling of transferred prescriptions, except controlled substance prescriptions
3.
Compounding drugs
4.
Preparing or mixing IV drugs for injection into a human patient
5.
Receiving oral orders for prescription drugs, except orders for controlled substances
6.
Subject to section 16215, performing any other functions authorized under rules
promulgated by the department in consultation with the board
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Training: Technicians
Pharmacy technicians must earn 20 hours of continuing education credit every
two years in Michigan.
 Of those 20 hours, credit must now include…
 One hour of pharmacy law
 One hour of patient safety
 One hour of pain and symptom management
 Five hours of live CE credit to renew their license.
 Licensees who received their licenses prior to June 30, 2015, will need to begin complying with
these requirements prior to their next renewal period
Technicians who will have been licensed for less than two years, but greater than one
year as of June 30, 2016, will be responsible for having half of these credits met at the
time of renewal.
Employer based training, publications and other educational activities are great
ways to further the skill sets of technicians
Keeping up - Pharmacists
Pharmacist C.E. Requirements: Michigan
 30 hours every 2 years
 10 hours must be “live”
 1 hour must involve “Pain Management”. (no more than 12 hours in
a 24 hour period). All hours should be reported to NABP CE Monitor
 Now must complete Human Trafficking training
 Subscriptions to pharmacy publications, books etc
 The more you know, the less likely you are to make an error!
Pharmacy Environment: Create a
culture of safety
 A positive work environment leads to less stress
 Distractions should be minimized
 Focusing on developing your team’s skill sets will help decrease stress and
increase your overall job satisfaction
 Can you handle working long hours or will you be sharper and more detail
oriented working shorter shifts? How about working multiple days in a row?
We are all different.
 Are you taking time to rest and utilizing vacation time?
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How to handle a dispensing incident
1.
Pull the patient to an area of the pharmacy that is away from other
patients.
2.
APOLOGIZE – simply being nice and caring go a long way!
3.
Sympathize: No matter how “little” of an error it is, patients do not
know that and it can be a frightening experience
4.
Correct the error and make sure the patient knows he/she has the
correct prescription with the correct information.
5.
Follow your company’s reporting procedure.
6.
Do a root cause analysis for how the error happened and what you
can do differently to PREVENT the error from happening again.
LEARN FROM YOUR MISTAKES.
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