Pharmacist Dispensing Error

Dispensing errors account for 6%-12% of all medication mistakes. These mistakes are made by pharmacists or pharmacy technicians. In a study of 500 pharmacist malpractice claims, over 85% of dispensing errors could have been prevented.

Common dispensing mistakes made by the pharmacy staff include:

• Dispensing the wrong drug: This happens when the patient’s doctor prescribed the correct medication, but the prescription was filled by the pharmacist with the wrong medication.
• Dispensing a prescription to the wrong patient: Here the prescription is filled correctly, but is given to the wrong patient by the pharmacy staff.
• Dispensing the wrong dosage of the prescribed drug: In this case the doctor prescribed the correct dose, but the wrong dose was dispensed.
• Confusing drugs that have similar sounding names or look alike: This is a common mistake. Examples of this include Glyburide, Glipizide; Quinine, Quinidine; Serzone, Seroquel; Lamictal (for epilepsy), Lamisil (for nail infections).
• Failing to verify a drug name or dosage with the prescribing doctor.
• Failing to protect against harmful drug interactions: This occurs when a pharmacist does not check if a patient is currently taking other medications that can affect the efficacy, side effects or action of the prescribed drug. This includes not only interactions between two or more medications, but also the harmful combination of a drug with certain foods or beverages.
• Failing to identify patient drug allergies: This occurs when the pharmacist fails to determine whether the patient is allergic to the prescribed medication, its ingredients or any of the substances from which the drug may be made.
• Failing to give the correct directions for taking the prescribed medication.
• Mislabeling a prescription: This occurs when a label has improper use instructions or inadequate or erroneous warnings.
• Failing to provide adequate counseling to the patient.

Common causes of pharmacy error include:

• Inadequately trained personnel.
• Improper abbreviations used in prescribing.
• Inappropriate use of decimals.
• Illegible handwriting: illegible handwriting on prescriptions or orders alone count for 15-25% of all medication errors.
• Inaccurate drug history taking.
• Labeling errors.
• Insufficient filling time / excessive workload.

Regarding chain drug stores in particular, a 2008 USA Today Investigation found evidence that corporate policies such as allowing or encouraging pharmacists to fill hundreds of prescriptions daily and rewarding fast work-can contribute to serious or fatal pharmacy errors.

• Lapses in individual performance.
• Poor oral and written communication between prescriber and pharmacist: one in ten medication errors results from an incorrect name, misinterpretation of dosage, misunderstanding of an abbreviation or misinterpreting the decimal point placement.
• Interruptions and distractions are highly correlated with dispensing errors. Almost 26% of pharmacists’ time is spent dealing with interruptions related to third parties and miscellaneous tasks.
• Drug reference files, texts, and/or other database systems may not be current, resulting in errors associated with outdated and incorrect information.