Not surprisingly, by far the most common complaint received at the College are ones made in relation to medication dispensing errors by pharmacists. From March 1, 2012 to February 28, 2013, a total of 60 formal complaints were received and reviewed by the Inquiry Committee about the following types of medication dispensing errors:
- Patients receiving the incorrect medication or strength of medication;
- Prescription labels containing incorrect information, or information inconsistent with the original prescription;
- Patients receiving the incorrect quantity of medication;
- Patients receiving an expired medication;
- Patients receiving medications which were incorrectly compounded; and
- Pharmacists not detecting drug interactions and/or clearly documented allergy information, resulting in adverse effects for the patient.
In almost all of the above instances, the dispensing pharmacist acknowledged that an adequate final product check was not performed on the medication(s) before dispensing to the patient, and not performing patient counselling. In some instances, the dispensing pharmacist acknowledged not reviewing the patient’s PharmaNet record while the prescription was transmitted to PharmaNet. The Inquiry Committee’s review found that all or some of these missed steps could have, in most instances, prevented the medication error and the subsequent complaint.
Reducing Errors and Increase Patient Safety by Following the Standards of Practice
Patient counselling for ALL prescriptions (including refills) is a legislated practice requirement, and is outlined in section 12 of the Community Pharmacy Standards of Practice (Bylaws to the Health Professions Act, Schedule F, Part I):
- Full pharmacist/patient consultation for Schedule I, II and III drugs should occur in person if practical, or by telephone and must respect the patient’s right to privacy.
- Full pharmacist/patient consultation is required for all prescriptions.
- Subject to subsection (6), a full, limited or student pharmacist must engage in direct consultation with a patient or the patient’s representative regarding a Schedule I drug, and must
- confirm the identity of the patient,
- identify the name and strength of drug being dispensed,
- identify the purpose of the drug,
- provide directions for use of the drug including the frequency, duration and route of therapy,
- discuss common adverse effects, drug and food interactions and therapeutic contraindications that may be encountered, including their avoidance, and the actions required if they occur,
- discuss storage requirements,
- provide prescription refill information,
- provide information regarding
- how to monitor the response therapy,
- expected therapeutic outcomes,
- action to be taken in the event of a missed dose, and
- when to seek medical attention, and
- provide other information unique to the specific drug or patient.
- If a drug-related problem is identified during full pharmacist/patient consultation, the full pharmacist must take appropriate action to resolve the problem.
- If an adverse drug reaction as defined by Health Canada is identified, a full pharmacist must notify the patient’s practitioner, make an appropriate entry on the PharmaNet record and report the reaction to the Canada Vigilance Program Regional Office.
- A full, limited or student pharmacist must use reasonable means to comply with subsections (1), (2) and (3) for patients or the patient’s representatives who have language or communication difficulties.
While it may not always be practical or accepted by a patient to counsel on all the above noted requirements for refill prescriptions, at a minimum the pharmacist MUST confirm that the right patient is getting the right drug/strength and ensure they know how to take it appropriately. The pharmacist must also provide a direct opportunity for the patient to ask questions. It is not appropriate to have the pharmacy assistant or pharmacy technician ask the patient “if they need to speak to the pharmacist”. In most cases, the patient “doesn’t know what they don’t know”.
A review of the patient’s PharmaNet record before dispensing each and every prescription(including refills) is also a legislated practice requirement under section 11(4) of the same legislation:
A full pharmacist must review the patient’s personal health information stored on the PharmaNet database before dispensing a drug and take appropriate action if necessary with respect to:
- appropriateness of drug therapy,
- drug interactions,
- allergies, adverse drug reactions and intolerances,
- therapeutic duplication,
- correct dosage, route, frequency and duration of administration and dosage form,
- contraindicated drugs,
- degree of compliance, and
- any other potential drug related problems.
Performing a Thorough Final Check
While there is no standard or legislated method to “check” a prescription before it is dispensed to the patient, the Inquiry Committee found that the most common missed step in the checking process for the complaints received was the checking of the information on the prescription label against the original prescription. The following checking practices are commonly recommended by the Inquiry Committee to pharmacists in order to avoid a recurrence of a medication dispensing error which can easily be avoided by a thorough checking process:
- Read the original prescription first, and then review the prescription label to ensure it is consistent with the prescription and/or hardcopy;
- Initial both the original prescription or hardcopy to indicate you have read the original prescription or hardcopy; and
- Circle or check-mark the patient’s name, prescriber’s name, drug name, strength, quantity, directions, and refill information to indicate that you have read the original prescription and reviewed these aspects on the prescription label. Also check the expiry date on all stock bottles. All pharmacists must be aware that these steps may become rote and routine – you must always be aware of what they are circling or check-marking.
What happens if I made a medication dispensing error and the patient makes a complaint about me?
The Inquiry Committee’s general approach to professional practice concerns such as medication dispensing errors is remedial as opposed to strictly punitive (unless fraud and/or intentional contravention of the legislation is involved, or there is a pattern of negligence/incompetence established). For the majority of complaints involving a medication dispensing error, the Inquiry Committee finds that the most appropriate remedial measure is requiring that the pharmacist and/or pharmacy manager reflect on the error and more importantly, the probable cause of the error. Pharmacists are usually requested by the Inquiry Committee to undertake (i.e. make a written, professional commitment) to take certain steps to change or enhance their practice to prevent a recurrence of the error. Pharmacy managers are usually requested to reflect on the policies and procedures in the pharmacy to see what could have contributed to the error, and the Inquiry Committee can request an undertaking from the pharmacy manager to make improvements in quality management procedures in the pharmacy to prevent a recurrence of the error.
If a similar error were to recur at the same pharmacy or with the same pharmacist despite a previous undertaking to make practice changes to prevent a recurrence, the Inquiry Committee may take more stringent action than remediation if it appears that the pharmacy and/or pharmacist has not complied with their previous undertaking.
If you have any questions regarding the complaints process, please contact the College and ask to speak to a Complaints Resolution Officer.
- Dispensing Errors