Dispensing errors can happen to any pharmacist, and it is important to be prepared when this occurs.
In this article, Lara Marín, Professional Services Pharmacist at the IPU, provides an overview of what steps you need to take during such an eventuality.
No matter how experienced you are as a pharmacist, at some point during your practice you may make a dispensing error and you need to be prepared for when the time comes. A dispensing error can be defined as a deviation from a prescription that occurs during the dispensing process. They can take many forms such as:
When a dispensing error takes place at the pharmacy, it can be a very stressful moment for those involved. If you are involved in a dispensing error, you should seek help to support you in both managing the incident and coping with the aftermath and the impact on your practice.
Every pharmacy should have a quality assurance process/SOP in place to ensure that dispensing errors are dealt with accordingly and in a timely manner. The pharmacy team should be trained on this and should be aware of how to proceed when the incident presents itself.
The process in place at the pharmacy will provide you with clear guidance on the steps to follow, which are outlined below.
The patient may report the incident, or there may be times in which you may discover the dispensing error before the patient does. In that case you will need to contact the patient and inform him/her about the dispensing error. In all cases you should provide a sincere apology/expression of regret, even if it was not you who made the error.
You may need to clarify if the medication was already used or ingested and for how long. You should check how the patient is feeling and try to retrieve the incorrect medication. You will need to contact the patient’s GP or prescriber to inform them of the incident and to seek advice on how to proceed in the interests of patient safety, ongoing monitoring and continuity of care.
You will also point the patient towards a reference person. This designated person, preferably one in a governance role, will address his/her queries and provide assurance that the incident is being investigated and that actions will be taken to minimise the risk of a similar error happening again.
The incident also needs to be reported to those in governance roles within the pharmacy —the superintendent pharmacist and the supervising pharmacist. They will participate in the investigation process and will have oversight of the whole error management process.
You may also consider contacting the pharmacy insurance provider and providing an update on the situation. They have a legal team that can provide you with legal advice and support if required.
You will create a record about the incident or dispensing error that took place. You may have an electronic system in place at the pharmacy, that prompts you with questions while completing the report. Or you may have a template (such as those provided by the Pharmaceutical Society of Ireland (PSI)) that contains different sections to complete and that guides you through the process of recording the dispensing error. This record will initially contain the information regarding the incident such as what occurred, who discovered the incident and how it came to your attention. Over time this incident report will be expanded to include details of interactions with the patient and the patient’s GP, statements from the staff members involved in the dispensing error, risk assessment or gap analysis, a reflection of the event (for example a root cause analysis), and an action plan.
As part of the investigation into the incident those in governance positions, with the support of the pharmacy team, will review the dispensing process from beginning to end and will try to identify if there is any gap that led to the error occurring. The working conditions will also be reviewed, as external factors can also contribute to dispensing errors (for example, the lack of experienced personnel, busy environment, long working hours and lack of breaks).
Once you have reviewed the processes in place and any external factors at play, you can identify the factors that contributed to the error. You now have all the required information to develop an action plan and address the dispensing error.
Together with the pharmacy team you will develop and put in place preventative and corrective actions. By doing this you reduce the risk of the error happening again and increase the safety of the practice observed at the pharmacy;
Once an action plan is agreed is critical to share this learning with the pharmacy team. Fostering a no-blame culture at the pharmacy will promote a strong safety culture amongst the pharmacy team. Where relevant, sharing the learnings and outcomes with other colleagues, in a way that protects confidentiality, has the potential to increase safety practices in the pharmacy profession; and
Being involved in a dispensing error may have a deep impact on your practice and mental health. Sometimes pharmacists are afraid to ask for support and try to face these challenging times on their own. Those in governance should be vigilant and aware that dispensing errors may potentially affect staff members. Support should be made available at the pharmacy to help staff through the process and to promote a more resilient and positive work environment.
So, next time, if you face a dispensing error remember:
Lara Marín
Professional Services Pharmacist, IPU
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