dispensing errors

[joanne1]

hi there, im a pharmacy technician and i am currently doing a project about reducing dispensing errors. I need a couple of stories about actual dispensing errors that have occured. I am not having a lot of luck finding any interesting ones on the internet, just general information. I would be very grateful if anyone could forward an example or two about errors that they have heard about. Thank you very much.

joanne

[johannes]

Hi joanne1,
Google is our friend. If you fill in "dispensing error" in quotation marks, google will be much more friendly to us cause more selective.
Question, what is an interesting error, and what is a not so interesting one?

[crit care]

stories as in what errors have occurred??

some of the oens i ahve seen are basi errors...tabs supplied instead of caps...wrong froms of drugs, as in MR supplied when it should ahve been normal release...wrong types of inhalers, wrong strengths of drugs, wrong drugs with similar sounding names...spironolactone instead of sertraline i ahve seen....sando K instead of phosphate sandoz. there are a few for starters

the best thing to do si to look out for trends, i'm sure errors are made where you work? maybe ask your boss for a list of errors (if any)..is there somewhere where they are documented

[johnep]

Then there are classes of errors: Pick, transcription, switch etc.
johnep

[Nik]

Most recent one that springs to mind was the Elizabeth Lee case involving dispensing of propranolol instead of prednisolone. Mentioned a lot in the PJ over the last year.

[DavidS]

there is a "dispensing errors" section in this forum.
Pharmacy Errors

[El-loco]

Couple of examples - not necessarily mine!

Carbimazole 5mg tablets dispensed instead of 20mg (they look similar). Patient with thyrotoxicosis suffered because of it.

Morphine 10mg M/R tablets (MST) supplied instead of Morphine 10mg tablets (Sevredol). Delay in patient getting relief of pain.

But please remember that prescribing errors are fairly common and pharmacists regularly save patients from harm by dealing with these both in primary and secondary care - usually without much recognition for it.

[bobbin]

Couple of examples - not necessarily mine!

Carbimazole 5mg tablets dispensed instead of 20mg (they look similar). Patient with thyrotoxicosis suffered because of it.

Morphine 10mg M/R tablets (MST) supplied instead of Morphine 10mg tablets (Sevredol). Delay in patient getting relief of pain.

But please remember that prescribing errors are fairly common and pharmacists regularly save patients from harm by dealing with these both in primary and secondary care - usually without much recognition for it.

I'm sure there are a lot more prescribing errors than dispensing errors. Many never get picked up because pharmacists do not have access to much information about the patients that they are dispensing for.

[Web Ferret]

Full details of the Elizabeth Lee appeal - Gives background and how the law sees dispensing errors.

Lee, R v [2010] EWCA Crim 1404 (24 June 2010)

300 items single handed during the day.

If you want to reduce dispensing errors then have more trained staff and a second person verifying the final check. We are all human.

[tinx25388]

I'm sure there are a lot more prescribing errors than dispensing errors. Many never get picked up because pharmacists do not have access to much information about the patients that they are dispensing for.

We had an interesting one today. A patient, who until this morning, had not taken ANY pain relief, and has only just started on Paracetamol Suspension, was prescribed Fentanyl Patches 12mcg. We confirmed with the Care Home that this lady hadn't recieved painkillers from another pharmacy, but the Pharmacist couldn't believe it, needless to say after a conversation with the Doctor, we did not dispense them.