Methods of Avoiding the Errors in the first place

[howe928]

The best "tip" i ever read about for helping to check scripts was "read the script out loud", especially when dispensing and checking on your own (saturdays etc...): apparently, it's a different part of your brain that processes the information from your eyes, and that from speech & hearing;

hmm...sounds fun, does it work in a quiet pharmacy? other patient may overhead and potential breach of patient confidentility?

[Emmz]

If only all drug manufacturers followed Teva with their pack design, colour coding and space for labelling, then it would make dispensing safer all round.

But they have the same colours for different drugs! At the moment we've got Teva gliclazide and Teva codeine and they're both in exactly the same size box, exactly the same colours. Not a problem so much when dispensing cause they're not near each other but what if a patient grabs the gliclazide thinking it's their codeine and takes 8 in a day!

[SolomonQ]

Use anything at disposal to assess if any mistake has been made, e.g. quite recently I was giving out a prescription off the shelf, which needed to be signed for, so the Rx was with the bag, i noticed that the Rx was written for a few items including dispersable co-codamol (100), which is a large pack, but the pack I was giving out was quite small, I informed the patient I just needed to make a last check on it, and as thought the normal co-codamol tablets were being given out, even the label was written for normal co-codamol. so I change that and the patient just thought we missed something out.

A very good tip, and way of preventing errors which I think I invented (or atleast discovered independantly) is to read the Rx backwards. e.g.

Felodipine MR 2.5mg tablets
one twice a day
56

reverse read the first line, so:

Tablets 2.5mg MR Felodipine
1bd (vice versa if written this way on Rx)
2 packs (depends on pack size available)

This way easily eliminates alot of errors e.g. where you might misread the Rx to say felodipine 5mg MR, or where there are capsules and tablets for the same strenght you avoid picing the wrong one.

TRY IT!!!!

[kemzero]

I thought felodipine was long-acting , hence should be a daily dose not BD ;never seen it as BD too

[SolomonQ]

it is, thus the MR in the name above, and the BD im sure ive seen, maybe the doctor was fidling with the dose regimen etc.. e.g. patient needed 5mg MR OD but the doctor saw better control with 2.5mg MR BD.

saw same being done with doxazosin 4mg XL BD, patient converted to 8mg XL OD (Cardura) which didnt suit him, so got put back on 4mg XL BD.

seen quite alot things for "a nearly qualified anything "

[DavidS]

Not so important from a patient safety point of view, but much more so for a pharmacist safety point of view:

I've noticed that CD's are a bloody nightmare. There is so much to "tie up." What I've started doing is, having completed the dispensing, checking the balance in the register against the cupboard before the stuff leaves the shop.

It doesn't work with the likes of methadone, of course, but with the odd one-off scripts it gives you a chance to sort out errors when you can do something about them.

[Additionally, from a safety point of view, its remarkable that with cds they expect us to add out of dates into the running balance, and to store them together, regardless of the safety issues, whereas if we did that with normal stock - well, I've seen it mentioned as bad practice in stat comm proceedings.]

[posey]

make a physical tick on the box next to each bit...
name of drug,
form
pack size

helps it register in my head better.. and somehow ticks on the box reassure me!

[DavidS]

helps it register in my head better.. and somehow ticks on the box reassure me!

I've been trying this out since you posted, and, particularly with my "weak" spots (allopurinol/amiodarone, etc) it IS reassuring! Ta.

[medical6969]

Does anyone know of any research into how to avoid errors? Surely there must be some lessons to be learnt from the aviation industry / NASA / etc.

I know there have been a few conferences about dispensing safety in recent years. Has anyone been?

Healthcare Events

[shan]

Does anyone know of any research into how to avoid errors? Surely there must be some lessons to be learnt from the aviation industry / NASA / etc.

I know there have been a few conferences about dispensing safety in recent years. Has anyone been?

Healthcare Events

"To Err Is Human" Some wise men said this long long ago (don't know who)

Even they do mistakes. If you don't belive then look at the disasters in the past 10 years in aviation/ space industry and you will se they are of much grave in nature than the errors in a Pharmacy. IMHO best way to avoid errors is to stay calm and be vigilant (which in most cases is impossible, given the conditions we work under these days)

Shan