Enhancing the Accuracy of Dispensing Prescription Medications: Guidelines for Pharmacists

With the ever-increasing number of available prescription medications, opportunities for errors related to drug names, packaging, indications and adverse events are also increasing. Pharmacists must play a key role in preventing errors from occurring and in helping protect patients from harm when errors do occur.

This Web site, intended for professional use, suggests measures that pharmacists can take to enhance medication safety and provides links to additional professional resources.

Defining medication error
The National Coordinating Council for Medication Error and Prevention (NCCMERP), a national coalition of 20 organizations focused on prevention of medication errors, has approved this working definition of medication error:

“Any preventable event that may cause or lead to inappropriate medication use or patient harm, while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems including: prescribing; order communication; product labeling, packaging and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use.”

Medication use is a complex process that includes a series of steps—medication prescribing, order processing, dispensing, administration and effects monitoring—any one of which could lead to medication error.

Several national organizations whose missions are focused on enhancing the safe use of prescription medicines have developed practice guidelines and tips for pharmacists. The following represents some of their key recommendations.

Tips for pharmacists to reduce medication errors

• A pharmacist should always review prescriptions and medication orders before dispensing. Orders that do not contain all the required information, that are written illegibly or that pose any other concern should be clarified.
• Obtaining the patient’s pertinent demographic and clinical information will help practitioners select the appropriate medications, doses and routes of administration. Having complete patient information at the time of prescribing and dispensing will result in a significant decrease in preventable adverse drug events (ADEs).
• The medication dispensing area should be designed to prevent errors by:
• Addressing fatigue-related environmental conditions (adequate lighting, air-conditioning, noise reduction, ergonomic fixtures)
• Minimizing distractions (telephone and personnel interruptions, clutter, unrelated tasks)
• Providing staffing and other resources appropriate to the workload.
• Product inventory should be arranged to help differentiate medications from one another. This may include the use of visual discriminators such as signs or markers. This is particularly important when there is confusion between strengths, similar-looking labels and names that sound or look similar.
• Checks should be established to assess the accuracy of the dispensing process before providing the medication to the patient. For example, whenever possible, a second individual should perform an independent check. Other methods of checking include automation (such as bar-coding systems), computer systems and patient profiles.
• Labels should be read at least three times:
• When selecting the product
• When packaging the product
• When returning the product to the shelf.
• Pharmacy staff should triple-check the replenishing of regular medication stock or automated dispensing machines or cabinets to ensure that each product is stored in the correct place:
• When selecting the product
• Before the product leaves the pharmacy
• Before placing the product in the automated dispensing machine/cabinet.
• Pharmacists should counsel patients at the time of dispensing and should regard counseling as an opportunity to verify both that the correct medication is being dispensed and that the patient understands its proper use. Counseling should include:
• Indications for use of the medication, as well as precautions and warnings
• Expected outcome of the medication
• Potential adverse reactions and interactions with food or other medications
• Actions to take when adverse reactions or interactions occur
• Storage requirements of the medication.
• For continuous quality improvement purposes, pharmacies should collect and analyze data regarding actual and potential errors—for example, by providing feedback to local prescribers or providing error information to national reporting programs and databases.
• Pharmacies should conduct both initial and ongoing staff training on the standards of practice regarding accurate dispensing processes.
• Each pharmacy should establish policies and procedures for the medication dispensing process. This will ensure that all personnel—pharmacists, support staff and relief staff—are informed of dispensing-process expectations.
• Providing accurate and usable drug information to all healthcare professionals involved in the medication use process reduces the number of preventable adverse drug events. Not only should drug information be readily accessible to staff from a variety of sources (drug references, formulary, protocols, dosing scales) but also the drug information must be up-to-date and accurate.
• Staff education should focus on priority topics, such as: new medications being used in the hospital, high-alert medications, medication errors that are known to have occurred both internally and externally, protocols and policies and procedures related to medication use.