Methods of Avoiding the Errors in the first place

[DavidS]

My own routine is to insist that labels line up with the same name on the packet, so I don't have to turn the packet round or over, regardless of what the label covers, or if it goes around corners, etc. I have found this has saved me SO many times: not only do I notice, but dispensing staff tend to spot their own errors more often and when they double check my labels, as in boots, etc., they find it easier too! It doesn't stop them complaining about it though.

Another useful spin-off is that on the one occassion a mistake got as far as a patient (ok, that I know about), they were on the phone in two minutes saying that THEY had noticed straight away, hence no danger.

What do YOU do?

[Zoggite]

Re: Methods of Avoiding the Errors in the first place

sounds like an excellent idea; I wish all boxes were designed like APS/Teva's, where the drug name is printed just above the space for the dispensing label...
The problems start with PI's, where you could be covering the only bits of printed information in English, if you stick the label directly below th licensed name; also, you could be obscuring the expiry date...

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; so, even if your eyes have convinced you that the box of amlodipine 5mg you've picked off the shelf is right for your script, when you hear yourself say "amiloride 5mg", you'll realise your mistake...
As they say in a certain supermarket: "Every little helps!"

[Jeff]

Re: Methods of Avoiding the Errors in the first place

What do YOU do?

Put the dispensed medicines in the bag with their names facing upwards so that the patient can check discreetly while in the pharmacy that what has been dispensed is what they are expecting.

Jeff

[DavidS]

Re: Methods of Avoiding the Errors in the first place

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; so, even if your eyes have convinced you that the box of amlodipine 5mg you've picked off the shelf is right for your script, when you hear yourself say "amiloride 5mg", you'll realise your mistake...
As they say in a certain supermarket: "Every little helps!"

Yes, I like that, and from what I know of neuroscience - which isn't much - singing the name might be even better!!

[lamzee]

Re: Methods of Avoiding the Errors in the first place

Always pack your own bags--don't check then leave for dispensing staff to cross-pack. Then re-check packet-ends once in bag.

[JonF]

Re: Methods of Avoiding the Errors in the first place

I've got into habit of marking original pack next to the drug name and the strength. I think the physical act of making a mark helps in checking strength and drug and it has helped me avoid many a mistake reaching patient.

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.

[Web Ferret]

Re: Methods of Avoiding the Errors in the first place

The new activis packing is pretty bad IMHO.

I read the script, then look at the medication, then finally read the label.

Having enough quality support staff & rest breaks seems the best method to avoid errors.

[johnep]

Re: Methods of Avoiding the Errors in the first place

Close one yesterday, two scripts, one for a Neville Turvey and other for Neville Turner. followed each other and got dispensed as neville Turner. Spotted because we owed one and owing label on script had different name to that on script.
johnep

[Pharmanaut]

Re: Methods of Avoiding the Errors in the first place

Used to hate dispensing Lofepramine and Loperamide. The old GUK livery didn't help at all. The were together on the shelf. They were soon separated.

[howe928]

Re: Methods of Avoiding the Errors in the first place

insist that labels line up with the same name on the packet, so I don't have to turn the packet round or over, regardless of what the label covers, or if it goes around corners, etc.

LOVE that, that's what i will do when i was a pre-reg; and keep this habit nowadays if i am the one sticking the label on


...........................................
HATE those who puts label up side down, how do they read that? do their eye just turn up side down for a second?

or the one that you need to read by turning it 3D

last not to mention the wonky going up or down hill labels

[howe928]

Re: Methods of Avoiding the Errors in the first place

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]

Re: Methods of Avoiding the Errors in the first place

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]

Re: Methods of Avoiding the Errors in the first place

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]

Re: Methods of Avoiding the Errors in the first place

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

[SolomonQ]

Re: Methods of Avoiding the Errors in the first place

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 "