Practice Insight

Practice Insight: Preventing Dispensing Errors

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Practice Insight explores concerns reported to the College as part of the complaints and reports process that present learning opportunities for pharmacists and pharmacy technicians. This close up on a complaint reminds pharmacists of their duty to provide patient counselling for new medication prescriptions, verify a medication prior to dispensing and keep clear, accurate and legible records.

Dispensing Error Accelerates Planned Surgery

A patient’s mother arrived at a pharmacy to pick up two prescriptions for her 13-year-old daughter—tramadol HCL 50mg and clarithromycin. Tramadol was to be taken if the patient’s pain could not be managed by acetaminophen and ibuprofen.

In error, the patient was dispensed trazodone HCL 50mg instead of tramadol HCL 50mg. As a result, the patient’s pain continued to worsen. The patient was admitted to the hospital and ultimately underwent necessary surgery sooner than expected.

Outcome from the Inquiries, Complaints and Reports Committee

Read the Outcome
Upon reviewing the complaint, a panel of the College’s Inquiries, Complaints and Reports Committee observed that as a result of the dispensing error, the patient’s pain was not properly managed.

The panel pointed out that the patient was provided with the incorrect medication and that no member of the pharmacy staff identified the error until it was brought to their attention by the complainant.

The panel observed that during counselling, the registrant should have noted that it is unusual to prescribe trazodone together with clarithromycin, and that the instructions for use indicated on the label and the hardcopy did not match the use of trazodone. The panel noted that the original prescription and hardcopy specifically indicated that the medication was to be used only if Tylenol and Advil did not manage the patient’s pain.

Given that the registrant was made aware of the intended use of the medication, the panel is of the view that the registrant should have been prompted to check the original prescription to ensure that the correct medication had been entered and dispensed.

The panel emphasized that had the registrant assessed the patient properly and used a therapeutic thought process during counselling, the error would have been noted prior to the patient receiving the medication. Further, given that the patient was a “red flag” patient and it would be unusual to prescribe trazodone for a child of her age, the panel observed that the registrant should have used greater diligence during counselling and verification.

Apart from adding a signature indicating counselling had been provided, the panel noted that the registrant did not make any specific notes regarding what was discussed during the counselling or any specific details such as the date, whether she had spoken to the patient or an agent, and any checks she conducted.

The panel is of the view that the registrant did not engage in sufficient reflection on the causes of the error or on how to address these causes to prevent errors in the future. The panel pointed out that this was a missed opportunity for continuing quality improvement, which ought to occur when any error is identified.

Finally, the panel is of the opinion that the registrant demonstrated a lack of insight regarding their professional responsibilities as a practicing pharmacist to work with care and attention to ensure the right medication is dispensed in the right dose, the right strength and with the correct instructions, as intended by the prescriber.

The panel issued the registrant advice/recommendations and required that the registrant complete specified remediation in order to provide the registrant with an opportunity to improve their practice within the areas of concern.

Error prevention techniques in pharmacy are geared towards optimizing public safety and patient well-being. Therefore, suitable checks and balances are in place to ensure that an error is detected prior to it being released from the pharmacy.

In the case of a prescription for a new medication, according to the Standards of Practice, the dispensing pharmacist would be required to counsel a patient at the time of the release of the medication to the patient’s custody. This discussion ensures that the drug being dispensed is the correct one, and that the dosing instructions are the same as those explained to the patient at the time the prescription was written. The pharmacist must also take this opportunity to discuss any possible side effects with the patient. This is the final opportunity for a pharmacist to correct a dispensing error, before the patient or an agent leaves the premises.

In addition, registrants must be diligent in identifying and responding to red flag situations that present in practice (Code of Ethics, section 4.9). Practice that has the potential for a high degree of harm to patients requires additional scrutiny by registrants.

Documentation is a key element of every health profession’s standard of practice and one of the most basic professional responsibilities. The Standards of Practice require that pharmacists keep clear, accurate and legible records that are consistent with applicable legislation, regulations, policies and standards. Patient records support the continuity of care and collaboration between and among health professionals. The documentation of patient care optimizes decision-making, helps to reduce duplication of services, and demonstrates the pharmacist’s decision-making process.

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