Hindering Human Error: Establishing Systems to Eliminate Drug Dispensing Errors

After ten years of tracking closed claims, the pharmacy underwriter group CNA and Health Care Providers Service organization, teamed up to publish a study which called for more systematic approaches to drug dispensing. According to the study, just over 75% of claims arose from patients receiving the incorrect drug or dosage. And, in over 20% of these cases, the mistakes made turned out to have severe consequences such as overdoses or even death.

The study was published in an attempt to raise pharmacist awareness of risk exposures and, ultimately, to increase patient safety.

The Sound Alike Drug Dilemma

According to the study, over 40% of claims paid were a result of the wrong drug being dispensed to the patient. Often times, the drug administered had a name that sounded similar to the correct drug. In this study, clonidine prescriptions were most commonly mistaken, being filled with Klonopin, conazepam, or glipizide. These errors were serious, causing injury to the patient and bringing with them an average six-figure claim payout.

To help reduce this occurrence, Allen Vaida, pharmacist and executive vice president of the Institute for Safe Medication Practices, suggests that pharmacies keep a “high-alert” list of drugs with similar names. Orders received that have drugs which fall on this list would receive an additional check to ensure that the correct drug is being dispensed, and pharmacists conduct a final check between the prescription bottle label and bag before dispensing it to the patient.

Other Reasons for Errors

Ken Baker, a Phoenix pharmacist and lawyer, works as an analyst to help develop pharmacy improvement systems. While he asserts that most medication mistakes are just the result of inadvertent human error, he gives a few other causes for dispensing errors:

  • Reckless conduct by the pharmacist or technician
  • Shortcutting standard checks or tests
  • Patient misidentification at mail-in pharmacies
  • Incorrect computer coding or selections by the drug providers

Additionally, many pharmacists feel pressured to work too quickly, especially when lines are long. Pharmacists fear that customers will switch to another pharmacy, and choose to prioritize revenue over safety.

Suggested Solutions

Across the board, experts says that each pharmacist, technician, and pharmacy must have quality-control systems in place and follow them. Baker suggests a system that includes multiple stations, with each station checking the accuracy of the preceding work. This could mean a station for receiving the prescription and verifying the patient information, a station for correct computer data entry, a station for filling the prescription, a pharmacist check, and a final drug review with the patient.

In addition, Baker calls for increased accountability within the pharmacies. He states “Every technician and every pharmacist ought to know that this was our percentage [of errors] this month, and last month, and the month before.” With that knowledge, pharmacists can set new goals each month and put a process in place for continuous improvement.

Ultimately, the aim is to help reduce the amount paid out in pharmaceutical claims and improve patient safety, creating a win-win for both the healthcare professionals and those they serve.


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