Preventing Dispensing Errors in Community Pharmacy
In recent years, the College has seen an increase in the number of complaints from patients who have received the wrong prescription when utilizing pharmacy services in BC.
Instances of improper dispensing at a pharmacy are typically the result of a registrant failing to perform their legislated duty as outlined in the Pharmacy Operations and Drug Scheduling Act (PODSA) or the Health Professions Act (HPA). Often, these failures occur in one of the following practice areas:
- Patient Identification Verification
- Profile Check
Pharmacists have a duty and a responsibility to ensure that the right patient takes the right drug at the right dose at the right time AND in the right way to ensure effective drug therapy and patient safety.
Failing to properly verify a patient’s identity, provide adequate counseling to identify side effects and adverse reactions and/or conduct a profile check, can have serious consequences on that patient’s care, including negative health outcomes, hospitalizations or even death
In one case, a pharmacist dispensed allopurinol to a patient which interacted with her existing medication, azathioprine. The drug-to-drug interaction between allopurinol and azathioprine is serious and well-known. Refill prescriptions for allopurinol were dispensed to the patient two additional times before the patient began experiencing symptoms of pancytopenia and was admitted to the hospital. The patient remained in the hospital for 18 days during which she received multiple blood transfusions and required blood tests to determine the cause of her symptoms.
The Inquiry Committee found that the Registrant failed to conduct a PharmaNet review, detect the drug-drug interaction and provide counselling at the time of dispensing.
The College would like to remind pharmacists of the importance of positively identifying patients, thoroughly reviewing their PharmaNet profile and ensuring that they understand the medication they are taking and how to take it appropriately to optimize therapy, promote adherence and ensure safety.
Patient identification verification is always the first step to providing effective pharmacy care. The Pharmacy Operations and Drug Scheduling Act (PODSA) Bylaws require that the identity of the patient is confirmed before providing pharmacy services.
Patient identification is a fundamental standard to ensure that the right patient gets the right drug.
At the time of dispensing, every prescription in community pharmacy must include written confirmation of the registrant who verified the patient’s identification, in order to take responsibility
For additional information, please refer to the full Patient Identification Verification Focus Area, and Professional Practice Policy 54 – Identifying Patients and Patient Representatives in Community Pharmacy and Telepharmacy Settings.
Pharmacists are required to ensure that patients know about the medication they are taking and that they understand how to take it appropriately. The Health Professions Act (HPA) Bylaws require a full pharmacist to consult with a patient or patient’s representative at the time of dispensing a new or refill prescription.
Every prescription, both new and refill, requires counselling by the pharmacist on their respective requirements, and must include a written confirmation of the pharmacist who performed the consultation. Simply having the pharmacy assistant or technician ask the patient “Do you have any questions for the pharmacist?” is not acceptable.
Similarly, when the pharmacist counsels, simply asking the patient if they have any questions without counselling on all requirements is not acceptable. A lack of questions from a patient is not considered declining a consultation. If a patient declines the consultation to the pharmacist, the pharmacist must document that the consultation was declined.
For additional information on Counselling in Community Pharmacy, please refer to the full Counselling Focus Area
The Health Professions Act (HPA) Bylaws require a full pharmacist to review prescriptions for completeness and appropriateness, and review patient personal health information for drug therapy problems, therapeutic duplications, and any other potential problems. A full pharmacist must also review PharmaNet before dispensing a drug and take appropriate action if necessary.
This means that for every prescription (both NEW and REFILLS), a full PHARMACIST must review the LOCAL PROFILE and PHARMANET to assess the appropriateness of drug therapy and resolve any drug therapy problems. In fact, at the time of dispensing, every prescription in community pharmacy must include written confirmation of the pharmacist who reviewed PharmaNet.
It’s important to note that although PharmaNet’s Drug Use Evaluation (DUE) and some local pharmacy software can provide useful information such as drug-to-drug interactions and duplicate therapy, they are simply supplementary tools that cannot replace a pharmacist’s assessment of drug therapy and up-to-date clinical pharmacy knowledge. Therefore, it is not acceptable to delegate a Pharmacy Technician or assistant to alert the pharmacist for a profile check only when flagged by the system, because every prescription requires a pharmacist profile check.
For additional information on Profile Checks in Community Pharmacy, please refer to the full Profile Check Focus Area.