Common dispensing errors and how
to avoid?

• Highlight common dispensing errors which occur in community pharmacies and learn from these • Identify how the NPA can support you in the event of a dispensing • Help you to improve patient safety, by adopting procedures within the pharmacy which promote good dispensing practices • Explain error reporting requirements • Discuss NPA's role as Medication Safety Officer for independents and how errors can be reported through the NPA • Help you to identify and manage risks Dispensing errors
Leyla Hannbeck MSc. MPharm Head of Pharmacy Services Definitions
Medication error - an incident in which there has been an error in the process of: o prescribing o dispensing o preparing o administering o monitoring, or providing medicine advice regardless of whether any harm occurred • Near miss - an incident that did not cause harm but which is judged to have had the potential to cause harm Causes of errors
1. Prescription errors
! Misreading the prescription ! Illegible handwriting ! Abbreviations ambiguous or misinterpreted ! Pharmacist unfamiliar with Latin abbreviations ! Units of measurement ambiguous or misinterpreted ! Incorrect calculations Can you read these prescriptions?
ondansetron or candesartan? 2. Dispensing errors
! Medicines with similar names ! Medicines with similar packaging ! Incorrect picking of the medicine ! Transposing the label or labelling the medicine ! Dispensing out-of-date medicine ! Not dispensing against the prescription ! Incorrect labelling Similar name
Similar packaging
3. Other causes
• Busy workplace • Stress • Distractions • Staff shortages • Giving the wrong medicine to the wrong patient • Omitting medicines • Lack of concentration • Lack of clinical knowledge High risk medicines
• May cause serious patient harm if dispensed incorrectly: o Narrow therapeutic range o Serious adverse effects if dose or administration !Opioid medicines !Oral anti-cancer medicines • NPA Standard Operating Procedures for dispensing certain high risk medicines following guidance issued by the NPSA How to minimise dispensing errors
Important to have a clutter free and organised dispensing Keep interruptions in dispensary to a Only allow competent pharmacy staff to put away dispensary stock Maintain workload of pharmacy staff at safe and manageable level Dispensing process
 Verify name of medicine if unclear or badly written  Clarify unclear or illegible doses before dispensing  Check abbreviations of medicine names or dosage units  Print dispensing label before selecting medicine from shelf  Use prescription to select stock, not dispensing labels or patient medication record (PMR)  Alert staff to medicines with similar names and packaging Dispensing process
 Involve two people in dispensing process where possible  Make final accuracy check against the  Calculations should be written down and double-checked  Pharmacist should take a short mental break between assembly and final check if working alone  Procedure should be in place to identify who was involved in dispensing and checking processes  Patient identity must be confirmed before prescriptions are handed over Clinical assessment of a
1. Check that the medicine is not contraindicated or should be used with caution in specific patient groups, such as: o Children o Elderly patients o Pregnant or breastfeeding women o Immunocompromised patients o Patients of certain ethnic backgrounds o Female/male patients Clinical assessment of a
o Interactions o Potential side effects o Dosage, form and route of administration o Duration of treatment o Other medical conditions o Monitoring requirements Final accuracy check
For each item, check:  Name on bulk pack or patient pack matches prescription  Strength of item against strength on prescription  Multiple packs are the same medicine and the same  Expiry date  Drug form of medicine against drug form on prescription  Quantity on prescription against dispensed medicine  Dispensed medicine against contents of bulk pack  Patient information leaflet is supplied Final accuracy check
 Check prescription against label for : Patient name Name of medicine Strength Quantity Dosage form Dose/instructions  Check label against product  Mark ‘checked by' box Near miss incidents
• Dispensing mistakes can Types of near miss be minimised if near • Incorrect drug misses are regularly • Out of date product reviewed and actions • Incorrect form • Incorrect label Ensure that all staff can access the near miss log • Item not given to patient/representative • The NPA ‘Near miss • Prescription misread register' is available from • Incorrect quantity • Incorrect strength Dealing with a dispensing error
• Provide patient/representative and patient's GP with any required information immediately if patient has been harmed • Inform patient/representative that a thorough investigation will be conducted and an action plan prepared to minimise the risk of re-occurrence • If patient has taken any of the incorrect medicine, ascertain whether they have been harmed • Always inform patient's GP if an incorrect medicine has been taken Dealing with a dispensing error
• Apologise to the patient/representative • Supply the correct medicine, if appropriate • Ascertain the patient's/representative's expectations • Carry out a root cause analysis • Follow pharmacy procedures for reporting the incident • Record, review and learn from the error(s) made Root cause analysis
o What happened o How o Why • Putting into place recommendations should reduce chance of incident recurring • Focuses on system that has gone wrong rather than the individual who has made the error Patient safety alerts
Medicines & Healthcare products Regulatory Agency
(MHRA) may issue advice, often in conjunction with
• Information also in Drug safety Updates• Sale of products may change • European Medicines Agency (EMA) is responsible for
European marketing authorisations and may issue advice • Marketing authorisation (MA) holders may issue
guidance, such as new dosing recommendations or contraindications Dealing with patient safety alerts
• Pharmacists need to be aware of any alerts or guidance issued and take appropriate action • When patient safety alerts are received, pharmacists  Implement all the actions relevant to them  Ensure all relevant staff are aware of the information and/or required changes  Where appropriate, contact doctors or refer patients to doctors to discuss treatment Keeping up to date with patient
safety alerts
 Sign up to NPA alerts  Check the NPA website  Sign-up to information email alerts from  Sign-up to email alerts from the Central  Check the European Agency website  Ensure the fax machine is always switched on and contains paper Medication Safety Officer (MSO)
• NPA's Head of Pharmacy Services is MSO for all independent community pharmacies in England with fewer than 50 branches • Responsibilities include: o Promoting safe use of medicines o Implementing local and national medications safety o Improving patient safety o Submitting medication error reports to National Reporting and Learning Systems (NRLS) o Improving reporting and learning from medication o Responding to requests from NHS England and the MHRA for further information about medication errors MSO page on NPA website
• Dedicated Patient Safety/MSO page on NPA website - o Patient Safety Incident Report Form o SOPs for high risk medicines o Patient Safety Alert Factsheet o Patient Safety Alert Audit Sheet o Recent patient safety alerts and news stories MSO page on NPA website
Patient Safety Incident Report Form
• Easy and quick to use, • NPA forwards information with tick boxes and drop (anonymously) to NHS England – no need for • Can print off copy for pharmacy to submit pharmacy use – useful for separate report to NRLS • Feedback has been good • Patient information is not • More members are using seen by NPA – pharmacy adds this by hand after • Guidance notes on completing the form are Common errors being reported
• Types of error: o wrong drug/medicine – 33% of reported errors o wrong dose or strength - 24% of reported errors • Examples of wrong drug/medicine: o Seretide instead of Serevent o Novomix instead of Novorapid o Chlorpromazine instead of chlorphenamine • Important factors – for those reports which ticked any: o 71% ticked "medicines with similar looking or sounding o 14% ticked "poor labelling and packaging" Contributing factors
• For reports that identified contributing factors, 56% selected "Work and environment factors" • This category includes poor/excess administration, physical environment, work load, hours of work and time pressures o Examples reported: o "self dispensing and checking, workload and not o "busy time of the day" o "busy, main dispenser off" Dispensing errors
Glyn Walduck, FCILEx NPA Insurance – what is on offer?
Insurance across the spectrum for members, pharmacists, families and those working in pharmacy practice e.g. PI, PL, legal defence to GI for shops, homes and personal lines What we insure you for.
Breach of your professional duty – all amounts you are legally liable to pay as compensation and costs for claims made against you for breach of professional duty caused by negligence or omission and costs Public liability – damages and costs in the event of accidental injury or death of any person and/or accidental damage to another persons property caused by your negligence or omission and costs Product liability – damages and costs for injury or death or accidental damage to another persons property caused by the retail sale or supply of products and costs What we insure you for.
4. Legal expenses: • Against prosecution for an offence arising from the conduct of the retail pharmacy business Legal expenses resulting from the representation by legal or other expert at Coroner's Inquests and other Fatal Accident Inquiries Legal expenses incurred in responding to a GPhC investigation and representation by a legal or other expert at Fitness to Practise hearings (Disciplinary/Health) up to a maximum of £5,000 plus VAT Who is covered?
• Members • Employees • Self-employed persons who are engaged by members e.g. locum What's it all about?
• NPA Insurance Professional Indemnity Cover • NPA Member Support Holistic approach and added value
What happens when it all goes
Responding to complaints
The Letter:
How to write it (Tip: Who ‘s overlooking my shoulder)
Communicate findings Risk management/steps taken to prevent repetition – revisiting SOPs and amending if need be Parliamentary and Health Service Ombudsman Beware of Standard Template Letters
- Goodwill gestures • Quadruple jeopardy - Police CPS - Police Service NI - Procurator Fiscal - Coroner - GPhC - NHS Your NPA and NPAI Working Together To
support, protect & represent
• Managing the press • Liaising with Pharmacy Services on ethical and competency issues • Feeding into consultations with policy e.g. Medicines Rebalancing Legislation and Sanctions guidance • Managing Risk with Professional Development - Delivery Driver Course When it all goes wrong
• Indemnity • Defence • Advice • Assistance • NPA Insurance Ltd • NPA Members PI Insurer Upcoming NPA Events


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