Safety & Error Prevention in the Pharmacy

What Constitutes an Error?

An error is any type of preventable event that may cause or lead to an inappropriate medication use or patient harm or death.

Types of Medication Errors

1. Prescribing - prescriber incorrectly orders the medication

2. Omission - failure to administer an ordered dose of medication

3. Wrong Time - medication given outside of schedule time frame

4. Unauthorized Drug - medication administered to a patient from an unauthorized prescriber

5. Improper Drug - patient given dose that is too high or low

6. Wrong Dosage Form - medication given is in a different form than what was ordered

7. Wrong Preparation - drug is incorrectly formulated

8. Wrong Administration - drug is given using wrong procedure or technique

9. Deteriorated Drug - medication is expired or integrity of ingredients has been compromised

10. Monitoring Error - failure to review for appropriateness, proper regimen, or dose, or failure to monitor side effects or lab results

11. Compliance Error - patient does not adhere to prescribed regimen

5 Rights of Medication Safety

The 5 Rights involving medication safety ensure the basics of medication dispensing are checked in order to prevent errors at different stages in the prescription dispensing process.

• Pharmacy personnel are expected to adhere to these guidelines to avoid medication errors.

The 5 Rights:

1. Right Patient - always make certain the patient identification information is correct

   1. Use at least 2 patient identifiers

   2. Have the patient state their name

   3. If at the beside, check the patient armband

   4. Enter profile information correctly and completely

2. Right Medication - verify that the medication is exactly what the physician ordered

   1. Match the name and strength on the medication bottle to the original Rx

   2. Check the NDC Number

   3. Use barcode scanning when available

   4. Perform 3 checks before administration of any medication

3. Right Dose - verify how many doses are to be taken per day

   1. Verify Rx for the dose

   2. Verify that the calculations are correct for how much medication should be given

   3. Verify the length of treatment is correct

4. Right Route - verify the medication is given the right route

   1. Verify Rx for route

   2. Ensure pt understands how to take it

   3. Don’t crush or split without verifying with the pharmacist

   4. Make sure the medication dosage form matches the ordered route

5. Right Time - the medication should be taken at the time specified on the Rx

   1. Verify the Rx for the proper time

   2. Use auxiliary labels if necessary to notify the pt of specific timing

   3. If administering medications, most institutions allow a 30 min window before and after the time it’s due

Why Errors Occur

• Look alike or sound alike names (LASA/SALAD)

• Equipment malfunction

• Illegible handwriting

• Improper transcription

• Unapproved abbreviations

• Inaccurate calculation

• Labeling errors

• Lack of documentation

• Ambiguous strength or concentration

• Lack of training

• Excessive workload, stress, noise

• Multitasking

• Deficiencies in communication

LASA/SALAD

The FDA reviews drugs each year to reduce confusion between drug names that look-alike/sound-alike. The Institute for Safe Medication Practices (ISMP) published a list of drugs that are commonly confused for one another.

Tall Man Lettering

The ISMP and TJC promote the use of tall man lettering as means of reducing confusion between similar drug names

• ex. buPROPion - busPIRone