Pharmacy Errors – Common Causes

1.7% of the 3 billion prescriptions filled per year result in an error. Pharmacy error doesn’t sound like a huge problem. But, when you break that down to errors per day and calculate that 4 out of 250 prescriptions filled daily contain a mistake, there is cause for alarm.

We can break down the errors into four categories:

• Commission
• Omission
• Malpractice
• Negligence

Examples of an error by Commission: (defined: duty given to a person)

• Miscalculating a dose
• Dispensing the wrong medication to the patient – either in the strength or the form

Examples of error by Omission: (defined: a failure to do something, especially something that one has a moral or legal obligation to do)

• Skipping the counseling to the patient
• Failure to look for adverse drug interactions or contraindications

Example of an error from Negligence: (defined: failure to take proper care in doing something)

• a pharmacist fills a prescription when the dose prescribed exceeds a safe limit

Example of an error of Malpractice: (defined: improper, illegal, or negligent professional activity or treatment)

• An example could be mistaking one “sound-alike” medication for the wrong medication and dispensing the incorrect medicine. (Such as Keflex and Keppra).

And results from any of these types of mistakes can be life-threatening to the patient, and the outcome could be tragic.

Let’s Examine The Common Causes Of Dispensing Errors:

Overworked Pharmacists. The experts say that the maximum number of prescriptions a pharmacist should dispense per day to ensure patient safety should be no more than 150. Yet, pharmacists are filling up to 250 per day in some cases! We can’t underestimate what fatigue can do to the pharmacist’s accuracy and awareness.

Distractions. Pharmacists (especially in retail locations) have many distractions, including FAX machines, Auto Fill voicemail, priority processing, and customers frequently at the counter, to name a few.

Cluttered Work Areas. In a fast-paced environment, you could imagine how usually impeccable storage solutions can become disheveled, leading to improper storage and even improper labeling of medicines. There can also be poor ergonomics related to the dispensing process, low lighting, and even the distraction of noise from a radio or an intercom system.

Computer Processes. Typically, the prescription process’s computerization aids the pharmacist, but this is not always the case. Even the computerized methods known as CPOE (Computerized Provider Order Entry) can be prone to error. For example, the lower case “L” can be mistaken for the numeral “1”. The letter “O” can be misinterpreted for the number “0”. The letter “Z” is misread for the number “2”. There have also been errors using computer software where the wrong patient is chosen in the system or even the wrong drug. (Again, those sound-alike drugs).

Two Common Causes For Errors In Dosage:

• Mathematical errors: inaccurate decimal point placement and confusion surrounding the difference between micrograms and milligrams.
• Oral or liquid medication (typically for younger children) can be improperly dispensed by parents when the syringe labeling is unclear or misleading.

Dispensing Errors Caused By Inadequate Labeling:

• Even computer generated labels have contained errors when the associated software is not updated.
• When nonessential information is included on the label, it can confuse the patient.

Errors Caused By Inadequate Communication And Counseling:

• Failure to educate and counsel patients
• Lack of understandable written instructions
• Failure to involve patients in “check” systems about other medications they are currently taking
• Lack of attention to patients when they question their drug therapy or when they express concerns

Up to 83% of dispensing errors can be discovered during patient counseling and have the opportunity to be corrected before the patient leaves the store! Your careful attention as a patient and the pharmacist’s care as an expert are both critical to your health and well-being.

If you have suffered due to a prescription error, contact our board-certified attorneys at 713-425-6445 for a free case review, or order our FREE e-book: “Making Pharmacies Pay for Their Errors.” The consultation by our certified attorneys is entirely free. We determine if you have a good case, and if we decide that you do, we will work with you on contingency. You pay nothing unless we collect a settlement on your behalf.