Top five tips for avoiding errors

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1. Compare the millilitres vs milligrams dose

Mixtures expressed in mg/ml are frequently implicated in dispensing errors reported to PDL. Examples of mixtures that seem problematic include methadone 5mg/ml, Ordine 10mg/ml and Predmix 5mg/ml. Not uncommonly, a script calling for a Predmix dose of 5mg is dispensed as a dose of 5mls which translates to 25mg being directed on the label. This error often has clinical consequences as a child given a higher than expected dose of a cortisone will be restless and will not sleep well. This in turn will distress the parents who will often escalate the matter concerning a child, irrespective of the impact of the error. Some pharmacists provide the actual dose in brackets so the above scenario would read: Predmix 5mg/ml. Give 5mls (25mg) every four hours. Expressing the actual dose in mg would hopefully alert the dispensing pharmacist that the dose dispensed was too high.

2. Watch those decimal points

Avoid using decimal points, especially in doses for liquids expressed in mls. An order for Ordine 10mg/ml, give 2.5mls four hourly should be written as either give 2 & 1/2 mls four hourly or give two and a half mls four hourly to avoid being seen as 25mls four hourly. Hospital drug charts are often misread where a decimal point is faint and missed.

A frequent victim of the decimal point is the drug Sifrol which comes in strengths of 0.375mg and 3.75mg. Numerous errors have occurred with this combination.

3. Positively identify the correct consumer

One of the most common errors seen by PDL is providing a correctly dispensed script to the wrong consumer. The error is easily prevented if the pharmacy staff ask open questions of the intended recipient of a prescription as opposed to closed questions.

Avoid asking questions such as ‘are you Bryan Black?’ and replace it with ‘can I please confirm your name and address?’. If language or hearing are barriers, ask to see the consumer’s Medicare card or a similar document so they can be POSITIVELY identified. Providing medication to the wrong person often has serious clinical implications, may result in hospitalisation, and there is a potential breach of privacy.

Read the recent PDL practice alert “Incorrect collection of medication” for a detailed scenario.

4. Always check the expiry date at the point of dispensing

It is surprising how many incident reports to PDL involve the provision of expired medication. Provision of an expired antibiotic mixture to a child will usually create a high state of anxiety in the parents as many people believe the outdated medication will harm or possibly poison their son or daughter. Most instances of expired medication being provided will have a low clinical impact but in some drugs, such as chemotherapeutics, the consequences can be severe.

By all means use pharmacy systems such as coloured stickers and short dated lists to manage stock but ALWAYS check the expiry date before the dispensing label is attached.

5. Familiarise yourself with relevant legislation and guidelines

A significant number of pharmacists find themselves in trouble with regulatory bodies or their State Health Departments because they don’t know what is required of them when dispensing certain classes of medication. A recurring problem that PDL sees is where pharmacists dispense S8 medications when the prescription is altered or forged. Each State has specific requirements and obligations when dispensing S8 drugs such as the need to contact a prescriber whose handwriting is unfamiliar to you. If the prescriber cannot immediately be contacted, usually after hours, most States in Australia have provision for providing a ‘verification supply’ of up to two days. This gives the pharmacist a chance to verify the prescription a day or two later.

Some other classes of medication require special endorsement on the prescription to indicate that the prescriber is qualified to order this class of drug. Examples of ‘endorsement required’ medications are retinoids, psychostimulants and medications for anovulatory infertility.

It goes without saying that the Dangerous Drug register should be up to date at any given time (a regulatory inspection) and in balance. If you have an unexplained discrepancy in the balance, your State Health Department or regulator must be notified.

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, Australia-wide.