Pharmacists navigate demanding workdays filled with frequent interruptions and competing priorities. In such a fast-paced environment, it’s understandable how pop-up warnings during dispensing can be overlooked or quickly dismissed. This Practice Alert highlights why these alerts deserve your attention — overlooking one could mean missing a critical warning that impacts patient safety.
What are PDL pop-up warnings?
PDL pop-up warnings are integrated into most dispensing software and serve as a vital checkpoint to raise awareness of high-risk scenarios during the dispensing process. They have existed as a checkpoint for pharmacists for many decades.
Frequently reported incidents to PDL form the basis of these warnings and are carefully worded with the aim of preventing future errors for pharmacists.
How PDL pop-up warnings can play a role in preventing errors
PDL routinely reviews incident data and trends reported by the profession. This insight informs the annual update and additions made to PDL pop-up warnings, ensuring they address recurring issues and high-risk scenarios where potential consequences are significant. For example, several semaglutide formulations are available, which has led to aspects of confusion in dispensing and supply to patients. A pop-up warning has since been generated to address this.
PDL works alongside pharmacy dispensing software providers to raise awareness around risk scenarios. If pharmacists become aware of errors during their dispensing process and feel a pop-up alert may reduce an error, they are encouraged to contact PDL or their software provider.
The following factors generally trigger dispensary pop-up warnings:
- “Look alike” and “sound alike” medicines – e.g. carbimazole, carbamazepine
- Medicines where brand substitution is not advised – e.g. clozapine, warfarin
- High risk medicines where errors involving incorrect strength can lead to significant harm – e.g. digoxin, methotrexate
- Liquid formulations which are dosed in mL – e.g. prednisolone, liquid morphine, methadone
A recent case reported to PDL involved the mislabelling of a paediatric prednisolone dose where the child received 10mL instead of 10mg. PDL suggests pharmacists include both mg and mL quantities on the label to improve the patient or caregiver’s understanding of dose.
An example of a PDL pop-up warning that may have helped to prevent this situation is below. These alerts may vary in appearance depending on the software vendor, but the wording will remain the same.
Pause and read before dismissing
Pop-up fatigue can be a challenge in busy dispensary settings where frequent alerts can become overwhelming or repetitive.
However, it is important to remember that every alert is a potential safety net and should be taken seriously. PDL encourages pharmacists to exercise professional accountability and treat pop-ups as risk filters, rather than interruptions or screen clutter.
PDL members can call 1300 854 838 for advice and incident support from one of our Professional Officers.
