By: Joseph Saffi, RPh
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Joseph Saffi is a St. John’s University College of Pharmacy graduate, class of 1985. He is currently the supervising pharmacist at Pathmark Pharmacy of Franklin Square in Long Island, New York, and has been working for Pathmark pharmacies since 1988. Mr. Saffi is also a community pharmacy preceptor with St. John’s University and Rutgers University schools of pharmacy.
I would like to discuss medication dispensing errors. One of my least favorite tasks as a supervising pharmacist is filling a variance report or what is known as the dispensing error report. Dispensing errors are inherent to our profession. With longer work hours, lack of meals and rest breaks (a topic of future discussion), and reduced staffing, errors are something every pharmacist will experience at some time. It is not a matter of “if” – but when. Hopefully, the error will cause no or minimal harm to the patient. In my experience, all errors cause some degree of mental duress to the pharmacist involved.
When filing these reports, two things continue to bother me: lack of documentation and the failure to communicate with the patient. Many times, I find that pharmacists place calls to a prescriber to verify prescription information and fail to document pertinent information (vital information such as who you spoke with and the date/time). Some pharmacists also fail to document the outcome of an intervention or doctor call. These pieces of information are important, both, to the legal team and a fellow pharmacist, and are impossible to recall after-the-fact or even minutes later.
Many of these errors, some serious, could have been prevented if the pharmacist had asked a few simple questions, such as “why did you go see the doctor?” or “have you received this medication in the past?” In fact, another great opportunity to prevent errors is during the counseling session with a patient. Questions such as “how were you told to use this medication?” or “what were you told to expect from this medication?” can provide pertinent information that can prevent or help catch a prescription error. I have found that many times, patients will produce an old vial or some other type of information that can clarify or justify why they are taking a medication at an unusual dose or if they are using the medicine for an off-label use.
In some cases, pharmacists made unsuccessful attempts to reach a prescriber, failed to question the patient or guardian, and dispensed what was thought to be the correct medication. The patient may not be your best source of information, but he or she is the best available source at the moment in our pharmacy. By engaging with the patient during a counseling session or during the process of filling a prescription, a wide range of errors can be prevented. This also highlights the need for a pharmacist to have a positive relationship with the patients and how we play a crucial role in the community as primary caregivers.
Hopefully, electronic prescribing will help reduce prescription errors due to legibility issues; however, keep in mind that these are not error-proof either. These “e-scripts” are as good as the person inputting the information and may be prone to mistakes. As a pharmacist, I have come across many prescribing errors associated with these electronic prescriptions.
To reduce the incidence of prescription errors, it is essential to adopt good work practices earlier in your professional careers. The skills you learn during your school, experiential rotations, and intern work hours will enable you to become a more proficient pharmacist. Remember to document all interventions and doctor calls with appropriate information, as well as build a strong relationship with your community and your fellow professionals. Community pharmacy is a scattered and hectic work environment, but we need to remain organized, energized, and focused.
