Dispensing Error

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DISPENSING ERROR

BY

K.SAMINATHAN. M.pharm, M.B.A,( P.hD) Allianze college of medical sciences


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DEFINITION OF MEDICATION ERRORS

• Any preventable event that may cause or lead

to inappropriate use or patient harm while the

medication is in the control of the health care

professional, patient, or consumer.

POINT OF ERRORPrescribers (doctors),Dispensers (pharmacists) Nursing staff Patient himself


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TYPE OF MEDICATION ERROR

Prescribing errorOmission errorWrong time errorUnauthorized/ wrong drug errorDose errorDosage form errorDrug preparation errorRoute of administration errorAdministration technique errorDeteriorated drug errorMonitoring errorCompliance errorOther medication error

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Types of Medication ErrorsPrescribing error

Incorrect drug product selection (based on indications, CI, known allergies, existing drug therapy), dose, dosage form, quantity, route or rate of administration, conc., or instructions for use authorised by physician; illegible Rx or med orders that lead to errors


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Omission error The failure to administer an ordered dose to a patient before the next ordered dose or failure to prescribe a drug product that is indicated.The failure to administer an ordered dose excludes patient’s refusal and clinical decision or other valid reason not to administer.


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Wrong time error

Unauthorized/ wrong drug error

Administration of medication outside a predefined time interval from its scheduled administration time

Dispensing or administration to the patient of medication not authorized by a legitimate prescriber


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Dose error Dispensing or administration to pt of a dose that is > or< than amount ordered by prescriber or administration of multiple doses to pt

Dosage form error

Dispensing or administration to pt of a drug product in diff dosage form than that ordered by prescriber


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Drug preparation error

Drug product incorrectly formulated or manipulated before dispensing or administration

Route of administration error

Wrong route of administration of the correct drug

Administration technique error

Inappropriate procedure or improper technique in the administration of a drug other than wrong route


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Deteriorated drug error

Dispensing or administration of a drug that has expired or the physical or chemical dosage form integrity has changed

Monitoring error

Failure to review a prescribed regimen for appropriateness & detection of problems, or failure to use appropriate clinical or lab data for adequate assessment of pt response to prescribed therapy


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Compliance error

Inappropriate patient behavior regarding adherence to a prescribed medication regimen

Other medication error

Any medication error that does not fall into one of the above predefined types



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Categorizing Medication Errors• Category A – has capacity tocause error

• Category B – error occurred• Category F – error resulted intemporary harm and requiredhospitalizationbut did not reach patient

• Category C – error reachedpatient but did not cause harm

• Category G – error resulted inpermanent harm• Category H – error required

• Category D – error requiredmonitoring or intervention topreclude harm intervention to sustain life

• Category I – error contributedto or resulted in death

• Category E – error resulted intemporary harm and requiredintervention


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DISPENSING ERRORS

• Errors that occur at any stage during the dispensing

process

• These errors may undermine the patient’s trust in the

pharmacist and increase the risk of litigation procedures

• Selection of the wrong strength/product.

• Mainly caused when two or more drugs have a similar

appearance or similar name (look –a-like/sound-a-like).

• Other potential dispensing errors include wrong dose,

wrong drug and wrong patient.


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DRUG NAMES THAT MAY BE CONFUSED


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APPERANCE CONFUSION


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IMPROVE: DRUG DISPENSING

1.Use generic names as far as possible.Use furosemide (Frusemide) instead of LasixUse diclofenac instead of Voltaren.Use domperidone instead of motilium

2.Eliminate drugs with similar drug names.3.Beware of drugs with similar appearance.

Improve – drug dispensing procedure

Staff training.State the drug attributes to be checked.Drugs should be cross-checked after dispensing.Checked by the doctor before issue to patients.


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MINIMIZING DISPENSING ERRORS

• Ensure a safe place for dispensing process.

• Use different brands or separate products

that look alike.

• Practice good housekeeping habits.

• Be knowledgeable of high risk drugs.

• Keep interruptions to a minimum and

maintain workload at a safe and manageable

level.


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WHY REPORT MEDICATION ERRORS?

• Improve patient safety

• Development of valuable educational services

WHO SHOULD REPORT MEDICATION ERRORS?

• Pharmacists

• Nurses

• Physicians

• Other health care professionals


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CONCLUSION• Health Care professional shares the responsibility for identifying factors to medication errors and for using that knowledge to reduce occurrences.

• Medication errors cannot be ignored when they occur due to the risk of medical litigation as well as the patient’s well being.

• Medication safety solutions must be upgraded. Those who fall behind have a greater risk of patients getting seriously ill or death• Preventing Adverse Drug Events which result from errors will reduce the likelihood of them occurring.• A multidisciplinary approach to solving the problem must be promoted. • An attitude of “no blame” should be adopted.

THANK YOU

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Dispensing Error