The Top 5 Mistakes Made in Pharmacies and Tips for Preventing Them
by Wesley Usyak, CPhT, M.Ed.png)
Both retail and institutional pharmacy environments have multiple tasks going on simultaneously. For example, phones can be ringing, while a patient is awaiting an influenza or a COVID-19 test in the pharmacy drive-thru, and a stat order is received from the hospital floor.
In chaotic events, a pharmacy technician and pharmacist are faced with the possibility of making an error that could be detrimental to a patient’s health. Some common mistakes include the following:
- Wrong dose
- Drug-to-drug interaction
- Prescribing error
- Compliance
- Patient monitoring
The bigger question… How do we prevent making these mistakes?
One common mistake is the wrong dosage formulation.
For instance, a tablet could have been prescribed instead of a capsule or liquid. To avoid a wrong dose, a technician or pharmacist needs to verify the dose on a prescription or order when it is presented to them. If not, the prescriber needs to be contacted immediately to fix the mistake.
A second common mistake is a drug-to-drug interaction.
Most times, retail or hospital environments have a patient database indicating all medications a patient takes. It’s also essential to verify how many retail pharmacies the patient uses. Patients visiting multiple pharmacies run the risk of drug-to-drug interaction. A tip to prevent drug interactions is communicating with patients about all medications they take, including over-the-counter and herbal supplements.
A third mistake is a prescribing error where the prescriber wanted a drug that may not exist or make sense.
Also, the error can be concentration, quantity, or route of administration. A pharmacist or technician can verify the correct medication during data entry. If any questions exist, a technician should alert a pharmacist or contact the prescriber to fix the mistake.
The last two common mistakes are compliance and monitoring.
These mistakes occur if a patient is non-compliant or monitoring from a pharmacy does not occur. Medication Therapy Management (MTM) is the key to fixing these potential mistakes. MTM helps pharmacies monitor the patient regimen and adjust medications or dosing to avoid duplicate therapies. The prescriber and patient should be consulted to make sure everyone is aware of the drug therapies and monitoring of drug regimens. These simple suggestions can help avoid potentially fatal mistakes moving forward.
No one ever said working in a pharmacy is easy, and if anything, the last two years have challenged us mentally, physically, and emotionally. Always remember taking a little extra time and double-checking will have the best outcome to avoid making a mistake that will harm a patient. The next time chaos occurs in your pharmacy setting, remember to take a moment to consider these tips to avoid a crucial mistake.
For additional resources:
https://www.ashp.org/News/2018/10/02/ASHP-Publishes-Guidelines-on-Preventing-Medication-Errors
Mizner, J. (2014). Pharmacy Technician Certification Exam Review. St Louis, Missouri: Cengage.