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By ISQua Tuesday. Nov 11, 2014

Combating Medication Errors

In Pakistan where the infusion of technology is slow especially in the healthcare organizations, the problem becomes profound as the options to curb this nuisance become limited. Our Pharmacy Services also face this challenge and strive to prevent these errors. 

Of more interest to pharmacy services are the “dispensing errors”. Wrong drug dispensing encompasses a great variety of sub-categories such as wrong drug, wrong strength, wrong dosage form, wrong quantity/volume etc. and each has a potential to lead to patient harm although severity can vary.

Correct drug dispensing is the hallmark of any efficient pharmacy services and a KPI as well. It helps in building reliability of service for its stakeholders (patients, doctors and nurses). Retrospective analysis of our own error trend indicates some common reasons for dispensing errors like: Lack of drug knowledge, lack of experience (novice staff), drug placement in wrong bin, distraction – lack of concentration and similar drug packaging and drug names (Lookalike sound alike – LASA drugs) etc.

Based on this review, our department devised strategies to curtail the most frequent causes. For example a checklist was developed for defining drug in the pharmacy system dictionary which encompasses all the necessary clinical checks in the system e.g. dose limits, class allergy information, disease interactions, restricted frequencies (e.g. sliding scale for intermediate/long acting insulins) and important pill identifiers/clues defined in the dictionary. This helps in proper physician order review, check for appropriateness of order itself and of filled drug at the time of dispensing. Moreover, staff training on simulation model was started in which pharmacists were asked to check a cart of medications in which specific errors were built in. A similar model was also developed for pharmacy technicians to simulate the drug filling part. Department also works closely with Pharmacy & Therapeutics Committee in choosing brands and products with minimum LASA problem and pharmacy has a right to substitute a product if the error potential is significantly high.

Without hi-tech gadgets like barcode technology, unit dose packaging and automated dispensing machines etc. hospital pharmacies can still devise effective ways and means of preventing major medication errors, though reliance on ongoing staff training and building people’s line of defense would be immense. 

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