How to Prevent 7 Common Prescription Mistakes

Pharmacy errors occur for many reasons. Some can be avoided by simply improving how staff function within a pharmacy, since multitasking and distractions during work are the leading causes of dispensing errors.¹

“Take steps to minimize distractions as much as possible when pharmacists are working on orders,” said Deborah Sadowski, RPh, MHA, director of pharmacy services at Deborah Heart and Lung Center in Browns Mills, New Jersey. This includes having sufficient staffing to allow pharmacists to work without routine multitasking and interruptions. Adding barriers to work stations can help pharmacists improve concentration without outside distractions.

Hossam Maksoud, PharmD, chief executive officer at Community Care Rx, Hempstead, New York, said that optimum organization of one’s work space, work environment, and workflow has also been shown to markedly reduce dispensing errors. Proper lighting, adequate counter space, and comfortable temperature and humidity can help facilitate a smooth flow from 1 task to the next, which reduces the chances of dispensing errors.² Developing a routine for entering, filling, and checking prescriptions helps in organizing workflow. In addition, working with 1 drug product at a time and affixing the label to a patient’s prescription container before working on the next prescription can help prevent mix-ups.

Approximately 83% of errors are discovered during counseling and are corrected before a patient leaves the pharmacy.³ “Therefore, it’s important to go beyond offering to counsel and actually provide counseling for every patient,” Maksoud said. “Open a container and show the actual medication to the patient during counseling, rather than handing it to a patient in a sealed bag.” Completing this process provides an opportunity for the patient to see the medication and ask questions if it looks different from what they’re used to getting.

Counseling should also include instructions on how to take a medication and the appropriate route of administration, because many dispensing errors are attributed to misunderstood directions for use.² Educating patients about safe and effective medication use promotes patient involvement in their health care, which will likely reduce medication errors, Maksoud added.

Now that you’re equipped with some general information on how to avoid prescription errors, here’s a look at 7 common mistakes and advice on how to avoid them.

Common mistake #1: Dispensed a similar, but incorrect medication.

How to avoid it: Using barcode technology at all touchpoints can reduce the risk of dispensing an incorrect medication, Sadowski said. Build barcode technology into the receiving process, as well as at points of dispensing and at bedside administration in hospitals. Physically separate medications that look or sound alike when storing them on shelves.

Keith Veltri, BPharm, PharmD, associate professor at Touro College of Pharmacy, New York, New York, and clinical pharmacy manager of family medicine at Montefiore Medical Center, Bronx, New York, suggests employing Tall Man Lettering (TML) to differentiate drug names that look and sound similar. TML, a term dubbed by The Institute for Safe Medication Practices (ISMP) in 1999, indicates a portion of a drug’s name in uppercase letters (eg, on stock bottles and electronic medication orders) to help distinguish lookalike drugs from one another and avoid medication errors. For example, in TML, “hydralazine” and “hydroxyzine” are written “hydrALAzine” and “hydroxyzine,” respectively.

Common mistake #2: Dispensed the wrong quantity or dosage.

How to avoid it: Using barcode technology is a key strategy to avoiding these types of errors as well, Sadowski said. Other strategies include storing different dosages in different physical spaces, such as a 200 mg strength on 1 shelf and a 400 mg strength 2 shelves lower on the opposite side. Most importantly, regardless of other technologies used, always read labels 3 times.

Recheck prescriptions whenever possible, ideally by another person and preferably by a pharmacist, Maksoud said, because confirmation bias and preconceived notions make self-checking a poor method to reduce errors. If another pharmacist is not available, delay self-checking. This will allow a pharmacist to study the prescription from a fresh perspective, which will help identify an error that they may have missed the first time.

Common mistake #3: Incorrectly entered data.

How to avoid it: Pharmacists shouldn’t second guess illegible or ambiguous prescriptions, nonstandard abbreviations, acronyms, decimals, and call-in prescriptions, which are frequently associated with medication errors.⁴ When in doubt, call the prescriber for clarification and promptly document it, Maksoud said. Immediately transcribe all verbal prescriptions to a blank prescription pad and read it back to the prescriber to ensure that you have correctly transcribed it.

Sadowski has found that using computerized physician order entry is the key to reducing errors from handwriting and incomplete information in medication orders. Minimizing the amount of free-text information required for order entry by providing pre-built drop-down menu choices with complete information helps ensure that providers accurately complete order entry.

Common mistake #4: Improperly stored a medication.

How to avoid it: Refer to package inserts and drug information references to ensure familiarity with proper storage requirements for all drugs. Using robust temperature and humidity monitoring systems for all storage areas including room temperature monitoring, freezers, refrigerators, and warmers are best practices, Sadowski said. These systems should provide continuous monitoring, providing real-time as well as historical data, and can send multi-level alerts when temperatures are out-of-range and allow documentation of actionable interventions that were taken when alerts were triggered.

Veltri recommends displaying a chart of common medications that require either refrigeration or freezing in the pharmacy. Routinely checking all medications on shelves and discarding any expired medications, regardless of where they’re kept, is also key.

In order to avoid mix-ups among lookalike drugs, Maksoud advises storing them away from each other. Medication bottles should be properly organized with labels facing forward. Routinely check all medications on shelves and discard any expired ones. Using storage bins, cabinets, or drawers can result in misplacing lookalike drugs. Lock up or sequester drugs with a high potential of causing errors.

Common mistake #5: Forgot to fully inform a patient about side serious effects or drug interactions.

How to avoid it: Jitu Patel, BPharm, MS, head pharmacist and chief compliance officer at Medly Pharmacy, Brooklyn, New York, advises pharmacists to build systems and technology that make it easy to communicate drug interactions and adverse effects to patients. During the first fill, build rapport with a customer by talking about the importance of adhering to their therapy and encouraging dialogue to build a personal connection.

When a patient receives their prescription from Medly, the patient is offered pharmacy consultation for their medication. “With any medication we dispense, whether we’re filling it for the first time or not, we include a small leaflet about a drug’s uses and [adverse] effects,” Patel said. “Counseling is also available via our mobile app or in-person at our pharmacy.”

When doing patient counseling at discharge from a hospital, review medications in advance and prepare important information ahead of time to ensure that no vital information is missed if a discussion gets side-tracked or other questions arise at the time, Sadowski said. If important information is missed, follow up with the patient as soon as possible to relay the information and answer any further questions.

Common mistake #6: Communication issues, particularly during transitions of care from one level to another.

How to avoid it: One of the most common causes of medical errors in general is failure to communicate effectively between caregivers, particularly as patients transition from 1 level of care to another, Sadowski said. Efficient hand-off strategies between care team members is crucial to preventing these avoidable errors. This includes creating a culture where 1 team member is comfortable questioning another at any level when clarity is needed or questions regarding orders or procedures arise. Having well-defined policies and procedures around communication is essential.

Common mistake #7: Making typos related to zeros and abbreviations.
How to avoid it: Misplaced zeros, decimal points, and faulty units are common causes of medication errors due to misinterpretation.⁵ A transcription or interpretation error involving a zero or a decimal point could result in a patient receiving at least 10 times more medication than indicated, which could result in serious consequences if the medication was levothyroxine or warfarin, for example.² Prevent such errors by using computer alerts or by only stocking a single strength of a medication, Maksoud said. These errors may be detected when reviewing label directions during patient counseling. ISMP offers a list of error-prone abbreviations, symbols, and dose designations. Being familiar with this information may also help prevent dispensing errors.

References:

1. Santell JP, Hicks RW, McMeekin J, Cousins DD. Medication errors: experience of the United States Pharmacopeia (USP) MEDMARX reporting system. J Clin Pharmacol. 2003;43:760-767. https://pubmed.ncbi.nlm.nih.gov/12856391/​
2. Cohen MR. Medication Errors, 2nd edition. American Pharmacists Association. 2007. https://doi.org/10.21019/9781582120928​
3. Ukens C. Deadly dispensing: an exclusive survey of Rx errors by pharmacists. Drug Topics. 1997;100-111. https://www.questia.com/magazine/1P3-11192915/deadly-dispensing​
4. Hicks RW, Cousins DD, Williams RL. Selected medication-error data from USP's MEDMARX program for 2002. Am J Health Syst Pharm. 2004;61:993-1000. https://doi.org/10.2146/ajhp060267​
5. Lilley LL, Guanci R. Careful with the zeros! How to minimize one of the most persistent causes of gross medication errors. Am J Nurs. 1997; 97:14.

Karen Appold is a medical writer in Lehigh Valley, Pennsylvania.