/publications/issue/2003/2003-08/2003-08-7319

Prescription-Dispensing Accuracy

Author: Fred M. Eckel, RPh, MS

Yes, medication safety is on the consumer?s mind. Is this really the right medication the pharmacist put into my container? Will this new drug interfere with the drugs I am already taking? We could list many other questions or concerns that patients have because of the media attention on this subject. It is usually the life-ending or life-disrupting mistake that becomes the focus of the public spotlight. As pharmacists, we want to counteract this impression, and certainly, as we think about what we do, we believe that we rarely make mistakes.

What do we know about prescription-dispensing accuracy? Flynn and colleagues recently published the "National Observational Study of Prescription Accuracy and Safety in 50 Pharmacies" in the Journal of the Amer-ican Pharmaceutical Association (March/ April 2003). This study was based on a technique using direct observation to detect errors. The technique is considered the most accurate method because it detects errors even when the participants are unaware an error has occurred. According to this study, a patient had a 1 in 30 chance of a new prescription being incorrectly filled. Of course, many of the errors were not clinically significant. It might be argued that any error has a potential to be significant, so pharmacists should be concerned about all errors. Based on this study, "1115 potentially important errors occur in every 1 million prescriptions, producing an estimate of 3.3 million potentially important errors among the 3 billion prescriptions filled annually in the United States." Because most of us have detected so few dispensing errors in our pharmacy, they seem manageable, and it makes us think that the problem of dispensing accuracy is insignificant. The reason for this may be that most inaccurately filled prescriptions are never detected. When prescription-dispensing accuracy is viewed from the perspective of the extrapolated figure, it becomes a real problem that needs addressing. We need to support measures that will make the dispensing process safe. Pharmacists should review this study to see the types of errors that do occur. Because wrong label information and instructions were the most common errors, it suggests the focus should be on the computer-entry process. This study showed that "inspection is the weakest part of the prescription fulfillment process," so more effort should focus on improving the pharmacist inspection accuracy. Armed with this study?s results, pharmacist managers are in a position to determine for their practice setting if everything possible is being done to reduce dispensing errors. Until we realize the seriousness of the problem, remove the mentality of blame, and see corrective actions as primarily system improvements, we will make little improvement in the dispensing system. Fortunately, these changes are beginning to occur.