Reminder: Be alert but not alarmed

Reminder be alert but not alarmed website image

In December 2020, PDL released a Practice Alert titled “Be alert but not alarmed“. This alert reminded pharmacists of some of the common dispensing errors reported to PDL. While much has happened within the profession since that time, it is concerning to see that many of the same errors and error types continue to occur. Factors that could lead to these errors continuing may include a simple lapse from good procedures or the addition of newly graduated and registered pharmacists who may be unaware of the past advice.

For these reasons PDL encourages all pharmacists to review this reminder and discuss the error types with all dispensary staff.

The two most frequent dispensing error types reported are:

  • Wrong drug supplied
  • Wrong strength supplied of the prescribed drug

Causes of these errors include:

  • Incorrect data entry of prescription details
  • Incorrect selection of the drug or strength in the dispensing software
  • Incorrect selection of the drug or strength from the shelf, with likely omission of barcode scanning or lack of awareness of scanner warning that wrong item was scanned

Factors involved in these errors include:

  • Lack of concentration due to distractions
  • Assumption the item was correctly selected in the software
  • Similar brand or drug names – “look alike, sound alike” (LASA) medications
  • Similar packaging, especially with the corporate generic brands
  • Multiple strengths of a drug listed in the dispensing software

PDL strongly urges all pharmacists and dispensary technicians to be aware of these areas of risk and to be consistent and vigilant in how they prepare prescriptions for supply.

The following lists are a combination of the 2020 Practice Alert with reporting data from 2022. See “Top 10 drugs in PDL incident reports” for the most recent article.

Wrong drug (LASA medications)

  • Carbimazole and carbamazepine
  • Tapentadol and tramadol
  • Drospirenone/ethinylestradiol (Yaz® 3mg/20mcg and Yasmin® 3mg/30mcg)

Wrong strength

  • Methadone and Suboxone® for treatment of opioid dependency
  • Oxycodone tablets, tapentadol tablets, morphine liquid
  • Methylphenidate tablets
  • Apixiban – 2.5mg and 5mg
  • Lithium – 250mg and 450mg
  • Corticosteroids such as Prednisone/olone tablets
  • SSRI’s & SNRI’s – higher or lower doses than prescribed

Caution with combinations

  • Metformin and combinations with gliptins or SGLT2 inhibitors e.g. Janumet®, Jardiamet®
  • Statins and statin combinations with ezetimibe
  • Antihypertensive combinations, including Exforge®, Exforge HCT®, Caduet® and Cadivast®
  • Paracetamol with codeine 8mg or 15mg but combination with 30mg codeine dispensed

Confusion with compounded medicines

  • Atropine eye drops 0.01% or 0.05% were mistakenly dispensed as Atropt® 1% drops. In the past, the 0.01% drops had to be compounded until a proprietary 0.01% product, Eikance®, became available. Strengths other than 1% and 0.01% need to be prepared in a facility that can compound sterile preparations.
  • Minoxidil 1mg tablet/capsule – mistakenly dispensed as Loniten® 10mg tablets.

Any occasion when the prescribed strength or form does not conform with a proprietary product requires review and confirmation. It should NEVER be assumed the prescriber has made an error. The above errors have occurred because the non-proprietary strength of the item to be compounded was overlooked or assumed to be an error by the prescriber.

Tips to avoid errors

  • Slow down, check carefully and ALWAYS check the duplicate.
  • Scan everything and ensure you confirm that a product has scanned correctly.
  • Scan every item, e.g. all 5 boxes of insulin should be scanned.
  • Separate medications in different locations if there is a risk of incorrect selection, e.g. separating locations for S3 levonorgestrel and fluconazole.
  • Use warnings in the dispensing software or on the shelf, e.g. Redipred – “Check dose for mg vs mL”. Dispensing software suppliers have included PDL pop-ups for a small number of high-risk medicines involved in dispensing errors. Check your system displays the warnings.
  • Schedule regular meetings for all dispensary staff to discuss risk management and review any near misses and errors.

The intent of this alert is to provide insights and discussion points leading to greater awareness of risk and its prevention. This information could form the basis of continuous quality improvement activities for pharmacists and technicians in any dispensary setting.

Remember that scanning is a tool to protect the pharmacist as well as members of the public.

For immediate advice and incident support, call PDL on 1300 854 838 to speak with one of our Professional Officers. We are here to support our pharmacist members 24/7.