Prescription-Dispensing Accuracy

Yes, medication safety is on the consumer?s mind. The patient may wonder: Is what the pharmacist put into my container really the right medication? Will this new drug interfere with the drugs I am already taking? I have started to feel worse since taking this new medication.

We could list many other questions that patients have because of the public spotlight newspapers and television have put on this subject. It is usually the life-ending or lifedisrupting mistake that causes the spotlight to be focused. Because these problems are highlighted frequently, it is easy for the consumer to think that all health care is dangerous. As pharmacists, we want to counteract this impression.

What do we know about prescription-dispensing accuracy? Elizabeth Flynn et al have just published a study on prescription- dispensing accuracy and safety (National observational study of prescription dispensing accuracy and safety in 50 pharmacies. J Am Pharm Assoc [Wash]. 2003;43(2):191-200). This study was based on direct observation to detect errors. The technique is considered to be the most accurate method of detecting errors because it detects them even when a participant is not aware that an error has occurred.

According to the results of this study, a patient had a 1-in- 30 chance of receiving an incorrectly filled new prescription. Of course, many of the errors were not clinically significant. It might be argued, however, that we should be concerned about all errors because any error has a potential to be significant. Based on this study, ?1,115 potentially important errors occur in every one million prescriptions, producing an estimate of 3.3 million potentially important errors among the 3 billion prescriptions filled annually in the United States.? This would seem to be an unacceptable rate.

Because most of us have detected so few dispensing errors in our pharmacy, they seem manageable, and it makes us think that the problem of dispensing accuracy is insignificant. This may be because most inaccurately filled prescriptions are never detected. Yet, when prescription-dispensing accuracy is viewed from the perspective of the extrapolated figure, we see that this is a real problem needing to be addressed.

We need to support measures that will make the dispensing process safe. Pharmacists should review this study to see the types of errors that do occur. Since wrong label information and instructions were the most common error types, the findings suggest the need to focus on the computer-entry process, although our tendency is to focus on the less frequent but often more dangerous wrong drug error. This study showed that ?inspection is the weakest part of the prescription fulfillment process.? Pharmacist managers are in a position to determine for their practice setting whether everything possible is being done to reduce dispensing errors. Until we realize the seriousness of the problem, remove the mentality of blame, and see corrective actions as primarily system improvements, we will make little impact on the dispensing system. Fortunately, these changes are beginning to occur.

EDITOR-IN-CHIEF

Fred M. Eckel, RPh, MS

Professor and Director

Office of Practice Development and Education

School of Pharmacy

University of North Carolina at Chapel Hill