Re: Dispensing Errors

[jcpmed]

Hi there

I was working in a pharmacy and the following happened:

A wrong item was dispensed to a patient by a pharmacist. He was supposed to dispensed Betnovate 0.1% Ointment but was given Betnovate RD 0.025% Cream.

Please can you tell me the standard practice, in terms of what action the pharmacy should take in this situation?

Plus how can this error be prevented from happening in the future?

How can the Pharmacy work with outside organisations to reduce pharmacy errors in the future?

Thanks for your help

[Sir_Dispensalot]

I smell an assignment answer!

If you're working in a pharmacy then you should look at the SOPs in that pharmacy as we can only give a generalised outline - the pharmacy you work in will have a specific SOP unique to the shop//chain/multiple which may differ slightly.

That is if you are working in a pharmacy now, JCP, and not looking for the answer to one of your uni assignments. If this is an assignment, please be more open and honest about it. If not, then I apologise. If it is an assignment we will move this thread to a more appropriate section.

[jcpmed]

Thanks for your reply

Definitely NOT an assignment question. Just a talking point to find out if anyone has experienced anything like this in retail pharmacy. If so, what happened and how it was dealt in your pharmacy.

Cheers

[PinkGlitter]

Basic checking might help, as drug, strength, quantity, directions and form are the basics. On this occasion both strength and form were obviously not checked.

[GAZ]

Hi there

I was working in a pharmacy and the following happened:

A wrong item was dispensed to a patient by a pharmacist. He was supposed to dispensed Betnovate 0.1% Ointment but was given Betnovate RD 0.025% Cream.

Please can you tell me the standard practice, in terms of what action the pharmacy should take in this situation?

Plus how can this error be prevented from happening in the future?

How can the Pharmacy work with outside organisations to reduce pharmacy errors in the future?

Thanks for your help

we have to start (imho) from a basis of knowing we are human and liable to make mistakes and put in place procedures to minimise the possibilitly of mistakes getting through to the end user - SOP's are supposed to be there to help in this process BUT are only one factor - others include working environment, distractions, adequate trained dispensary & counter staff etc - the NPSA produced a booklet aimed at minimising dispensing errors and would be a good starting point to look at

[howe928]

1) does any of you make any kind of marking on the scripts to say you are the pharmacist who responsible for that script?

2) if the SOP says you need to mark on the script to say you checked that script, will you do that? or ignore the SOP because fear of being investigated by relevant authorities
(remember you are the responsible pharmacist now)

3) if there were a dispensing error, are you more than happy to receive a notification to inform you about the error and be more careful next time?

4) some argue that because they were on duty that day and is on the rota sheet so they don't have to sign the 'checked by' box on the dispensing label or making any mark on a prescription, what about those scripts that labelled on the day they were on duty but checked by another pharmacist on the other day e.g. waiting for stocks to come

[PHARMAC1ST]

The error should be logged down in pharmacy errors book or log. Every pharmacy should have one. If not make a note on patient records. Put down whether the patient used it or not. If there was any compains in terms of patient harm other than "you bloody should have checked it before giving it out" line, make a note of that. Reassure the patient that you have rectified the cause of the error and that it will not happen again (ye right!). If patient is complaining of side effects (if in this case then be cautious for a dodgy claim ) then offer them advice or referral.

[roper]

Find the prescription and check the computer record. Sometimes a patient claims an error has occured when in fact the GP changed the medication and the pharmacist dispensed it accurately.
Check the label against the product and prescription. Was it an error in stock selection or in labelling?
Who was responsible for each step of the dispensing process? Was the item checked by the same pharmacist who dispensed it or by a second person? If same person, was a mental break taken. Did they follow SOP? Some SOPs require check marks next to form, strength and quantity on product packaging and most ask for a signature on the label to identify checker.
Can you identify time of day label was produced? Was it dispensed straight away or "bulk labelled" for dispensing later. Was the pharmacy busy at the time?

I have had a hospital contact me about incorrect insulin (cause of hospital admission?) and been most relieved to find (weeks later) that, although labelled on my shift, the checking initial was of a different pharmacist - the following day.

As to the letters informing of errors, they are horrible to receive but do serve a purpose. It can go a bit too far though when you receive one to say you gave peppermint peptac instead of aniseed!

[howe928]

like you said aniseed instead of peppermint, 28 instead of 30, tablet instead of capsule, GUK instead of ACTAVIS, sugared instead of sugar free...


Despite the introduction of standard operating procudre (SOP), there are still a loop hole where pharmacists who made dispensing errors are not traceable.

I am just wondering if something happened to the patient and you are the duty pharmacist or responsible pharmacist when the label was generated (e.g. bulk labelled), what will the statutory committees do if the pharmacist responsible is not traceable (e.g pharmacist did not initial his/her checking initial or the prescription or label with checking initial was destroyed or vanished) but you are the only pharmacist they can identify

very likely to recceive a warning letter?

[lamzee]

like you said aniseed instead of peppermint, tablet instead of capsule,

Are they seriously suggesting that these are "errors"? Is it somehow better to refuse to dispense a script, generate an owing and tell the patient to call again tomorrow because we do not have the "correct" flavour, or correct tab/cap ? Does anyone actually do this?