R E V I E W S & A N A LY S E S Errors Originating in Hospital and Health-System Outpatient Pharmacies Maximilian Straka, PharmD INTRODUCTION Patient Safety Analyst The overall dispensing accuracy rate in community pharmacies is estimated to be Michael J. Gaunt, PharmD Sr. Medication Safety Analyst 98.3% (77 errors among 4,481 prescriptions).1 Despite this level of accuracy, about 4 Matthew Grissinger, RPh, FISMP, FASCP errors occur per day in a pharmacy filling 250 prescriptions daily. Extrapolating these Manager, Medication Safety Analysis numbers means that an estimated 64 million errors occur during the dispensing of 4 Pennsylvania Patient Safety Authority billion prescriptions annually in America’s pharmacies.2 Outpatient pharmacies operate in a variety of settings, including entities affiliated ABSTRACT with or located within hospitals, health systems, and clinics as well as freestanding Although a majority of prescriptions pharmacies. The pharmacists who staff these pharmacies provide a variety of services dispensed daily in outpatient pharma- to the community, including dispensing prescriptions, administering immunizations, cies will be correct, errors can occur. providing medication-therapy management, providing patient education, and making Prescriptions dispensed in an outpatient recommendations for over-the-counter medications. setting are usually for a 30- and occa- When dispensing medications, pharmacists perform tasks that can be repetitive, yet sionally a 90-day supply, which means require high levels of professional training and optimal performance under consider- that an error may not be intercepted for able time constraints.3 Dispensing a prescription can involve more than 40 separate a month or longer, potentially causing steps.4 Combine this with the numerous distractions from telephones, e-mails, cus- patient harm. Analysts reviewed medica- tomers, and the supervision of technicians, and a system emerges that is perfectly tion errors reported to the Pennsylvania positioned to facilitate errors at any step in pharmacy dispensing process. Patient Safety Authority that occurred in outpatient pharmacy settings. Of the The outpatient pharmacy setting provides a unique problem, that errors might go 1,044 errors, the top three event types unnoticed for months and may result in negative outcomes. Patients usually receive a were wrong drug (19.6%, n = 205), 30-day supply of medication and possibly up to a 90-day supply with a prescription. If medication list incorrect (17.0%, an error occurs, the patient may end up using the wrong therapy or wrong dose for a n = 178), and wrong dose/over dos- significant period of time. age (14.7%, n = 153). More than Pennsylvania Patient Safety Authority analysts examined medication errors coded to half (56.2%; n = 587) of the events have occurred in an outpatient pharmacy setting to determine the types of events, the reached the patient. Error-reduction steps in the pharmacy dispensing process in which the event occurred (when that infor- strategies can be implemented in mation was available), and contributing factors. multiple stages of the prescription fill- ing process, including during triage METHODS and order entry, production, and point Analysts queried the Pennsylvania Patient Safety Reporting System (PA-PSRS) database of sale. Counseling patients about for errors from January 2005 through December 2016, looking for events that were their medication at the point of sale categorized as occurring in a hospital’s outpatient pharmacy setting. To identify poten- can intercept errors and help patients tial event reports, analysts queried the care-area field for: Pharm*, Phar*, or Rx* and take their medications appropriately the care-area name field for: out*, comm*, reta*, or amb*. This query yielded 1,044 and safely. (Pa Patient Saf Advis 2017 event reports. The medications involved in the reports were standardized to either their Jun;14[2]:55-63.) brand or generic name. A medication was considered to have reached the patient if the Corresponding Author medication left the control of the pharmacy or pharmacy staff and was dispensed or Matthew Grissinger delivered to the patient. Reporters assigned harm scores, which are adapted from the National Coordinating Council for Medication Error Reporting and Prevention harm index,5 and categorized events based on the type of error. ANALYSIS Event reports were categorized by their event type. The top five event types (Figure 1) comprised 69.9% of the reports. The top three event types were wrong drug, medica- tion list incorrect, and wrong dose/over dosage. The ages of the patients involved in the events were as follows: 9.8% (n = 102) involved pediatric patients (younger than 18 years of age), 73.6% (n = 769) involved adult patients (age 18 to 64), and 16.6% (n = 173) involved elderly patients (age 65 or older). More than half (56.2%; n = 587) Vol. 14, No. 2—June 2017 Pennsylvania Patient Safety Advisory Page 55 ©2017 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S of the events reached the patient (Harm Figure 1. Top Five Outpatient Pharmacy-Related Medication Error Event Types Score C – I; Figure 2). Analysts also iden- (N = 1,044) tified that 5.9% (n = 62) of the events submitted to the Authority involved deliv- NUMBER OF REPORTS ery of a prescription to the patient’s home 250 or other location. 205 (19.6%) 200 178 Wrong Drug (17.0%) 153 Wrong drug errors comprised 19.6% (14.7%) (n = 205) of all the errors, and 89.3% 150 106 (n = 183) of these errors reached the (10.2%) 88 patient. It should be noted that nearly 100 (8.4%) half (48.3%, n = 99) of the reports did not provide the names of both medica- tions involved (e.g., the report only listed 50 one drug when two drugs were involved) in the medication name fields. There were 0 Wrong drug 105 different drugs mentioned in reports Medication Wrong dose/ Wrong dose/ Wrong list incorrect over dosage under dosage patient and 147 unique combination of drugs involved in wrong drug errors. The most EVENT TYPE MS17413 common drug mentioned in reports of Note: Data reported through the Pennsylvania Patient Safety Reporting System, January 2005 wrong drug errors was the opioid analgesic through December 2016. traMADol (10.7%, n = 22), of which the majority (68.2%, n = 15) were drug mix- ups with traZODone, an antidepressant. Figure 2. Harm Scores for Outpatient Pharmacy–Related Medication-Error Events The next most common drug involved in (N = 1,044) wrong drug errors was metoprolol (5.4%, NUMBER n = 11), with 72.7% (n = 8) of the mix- OF REPORTS ups occurring between immediate release 600 metoprolol tartrate and long-acting meto- 480 prolol succinate. (46.0%) 500 The other wrong drug mix-ups worth 392 (37.5%) noting were within drug classes rather 400 than individual medications. Mix-ups between different oral contraceptive 300 products comprised 7.8% (n = 16) of the errors. Mix-ups between different insulin 200 106 products comprised 7.3% (n = 15). The (10.2%) 100 32 33 remaining 68.8% (n = 141) of the errors (3.1%) 0 1 0 0 0 MS17415 (3.2%) involved at least 121 different medica- (0.0%) (0.1%) (0.0%) (0.0%) (0.0%) tions. Following are examples of wrong 0 A B1 B2 C D E F G H I drug errors reported through PA-PSRS:* Incident Serious Event Patient received traZODone instead of traMADol. After taking the dose, HARM SCORE she fell on floor. She felt woozy and Reports of events that did not reach the patient (N = 457, 43.8%) sleepy. Received multiple traZODone Reports of events that reached the patient (N = 587, 56.2%) * The details of the PA-PSRS event narratives Notes: Data reported through the Pennsylvania Patient Safety Reporting System, January 2005 in this article have been modified to preserve through December 2016. Percentages add up to more than 100% because of rounding. confidentiality. Page 56 Pennsylvania Patient Safety Advisory Vol. 14, No. 2—June 2017 ©2017 Pennsylvania Patient Safety Authority tablets. Called pharmacy to report Figure 3. Top Five Types of Medication List Incorrect Errors (N = 178) error. Noticed tablets were different. ERROR TYPE Patient received traZODone instead of traMADol in his dispensed medi- Incorrect instructions 41 cation prescription. He actually took (23.0%) his wife’s medication that was also Medication not 24 filled incorrectly. discontinued (13.5%) Patient was prescribed triamcinolone 24 and label was typed for triam- Wrong strength (13.5%) cinolone. Nystatin was dispensed. Nystatin did not help the patient’s 20 Missed order (11.2%) poison ivy and additional predni- SONE was dispensed. 18 Duplicate order MS17416 Patient received Singulair [montelu- ® (10.1%) kast] 10 mg and Zyrtec® [cetirizine] 0 5 10 15 20 25 30 35 40 45 10 mg. Each bottle was labeled with opposite drug and directions. Patient NUMBER OF REPORTS had remaining Zyrtec from previous fill in her old bottle. Therefore, for a few Note: Data reported through the Pennsylvania Patient Safety Reporting System, January 2005 through December 2016. days, she had been taking two Zyrtec tablets and no Singulair. She reported feeling a little drowsier than usual. n = 22), an antipsychotic agent, was in- amount of drug the patient received. In Two tablets of pravastatin 20 mg volved in more than 10% of the medica- 11.8% (n = 18) of the events, the actual were found in a bottle of Paxil® tion list incorrect events. Nearly 28% product dose strength was correct, but the [PARoxetine] 20 mg filled by the (n = 49) of the events involved antipsy- instructions would have had the patient outpatient pharmacy. Pravastatin was chotics, while 12.4% (n = 22) involved take a higher dosage. Of these overdoses, in the robot and was exchanged out antidepressants. Following are some 85.0% (n = 130) reached the patient. In for Paxil. The pharmacist believes two reported errors in which the medication 14.4% (n = 22) of these events, the patient tablets of the pravastatin must have list was incorrect: took at least one dose of the medication. remained behind when exchanging Doctor wrote order for fentaNYL Discovery of some of these errors did not out for Paxil. The patient brought the [transdermal system] 12 mcg/hr, occur until the time of the patient’s first incorrect tablets back [to the pharmacy] change every 3 days, start today. refill (11.8%, n = 18) or even months after and the error will be addressed with Pharmacy had order in twice the initial dispensing of the prescription next training to be sure robot is empty for today. (7.8%, n = 12). There were 98 different of all drugs when exchanging out. drugs mentioned in wrong dose/over dos- Oxazepam 10 mg ordered. Entered as age reports, including vitamin D (5.2%, ZyPREXA® (OLANZapine) 10 mg n = 8), metFORMIN (4.6%, n = 7), hydro- Medication List Incorrect by mouth every 8 hours when neces- CHLOROthiazide (3.3%, n = 5), and The second most common event type sary. The patient did not receive lansoprazole (2.6%, n = 4). selected by facilities was medication list any Zyprexa. incorrect (17.0%, n = 178). Within this The following are examples of reported category, analysts identified 15 different wrong dose/over dosage events: Wrong Dose/Over Dosage types of errors. The top error types were Directions on the label were to inject The third most common event type was incorrect instructions (23.0%, n = 41), 0.4 mL (5,000 units) [epoetin alfa] wrong dose/over dosage (14.7%, n = 153). medication not discontinued (13.5%, via IV every 7 days. Actually, the cor- In 36.6% (n = 56) of the events there was n = 24), and wrong strength (13.5%, rect volume to inject for 5,000 units a two-fold overdose, while 3.9% (n = 6) n = 24). See Figure 3. At least 80 different is 0.25 mL. Labs drawn to assess involved a 10-fold overdose. Nearly 35% medications were involved in errors. harm. No harm to patient. (n = 53) of the event reports did not have Only SEROquel® (QUEtiapine; 12.4%, enough information to determine the Vol. 14, No. 2—June 2017 Pennsylvania Patient Safety Advisory Page 57 ©2017 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S A 60-year-old female was prescribed instructions leading to an under dose, and patient, although only two of the reports PROzac® [FLUoxetine] 20 mg by 4.7% (n = 5) had an incorrect quantity. indicated that the patient had ingested mouth, 2 capsules daily. Pt received More than 20% (n = 22) of the reports did the medication. Nearly 24% (n = 21) of 40 mg PROzac capsules (80 mg), not have enough information to determine the events occurred during the order which she took 2 of daily for one the type or cause of the error. Although entry phase, while 73.9% (n = 65) of the month. The doctor was notified by 78.3% (n = 83) of the errors reached the events occurred when dispensing the outpatient pharmacist. patient, only 20.8% (n = 22) of the incor- medications to the patient. More than a A prescription for vitamin D 5,000 rect prescriptions were actually taken by third (35.4%, n = 23) of the 65 errors that units daily was filled erroneously with the patient, with 11.3% (n = 12) of the occurred when dispensing the medica- 50,000 units daily, which the patient patients taking the dose for at least one tion involved home delivery services. In took for one month. month. There were 71 different medica- fact, more than a third (37.1%, n = 23 of tions involved in the errors, including 62) of the events involving home delivery A prescription written for [methotrex- lisinopril (5.7%, n = 6), levothyroxine were wrong patient errors. Following are ate] 10 mg was entered as 10 tablets (3.8%, n = 4), simvastatin (3.8%, n = 4), examples of wrong patient errors: (25 mg dose). This prescription was and furosemide (2.8%, n = 3). refilled two more times. A [subse- During the process of setting up home quent] prescription was called in and Following are reported examples in which deliveries via courier, one patient filled correctly, but [the patient’s] drugs were under dosed: received another’s medication via the mom kept giving as before. Error TraZODone 50 mg was processed mail, and vice versa. [The mix-up discovered after discussion with and dispensed instead of 100 mg. involved Xanax® (ALPRAZolam) the patient’s mother and review of The patient had trouble sleeping and and Truvada® (emtricitabine and medications with her. Physician made noticed the pills were different but tenofovir disoproxil fumarate)]. The aware of error. Confirmed that there didn’t say anything. The error was patient realized that the patient was no patient harm. caught on next refill. name [printed] on the bottle was not hers and recognized the medication Notified provider that he did not The pharmacy received a prescription was not prescribed to her. She con- write out units and that the pre- for tacrolimus 0.5 mg/mL electroni- tacted the pharmacy and returned the scription for [insulin regular] was cally and dose for the patient is 4 mg medications to pharmacy via mail. misunderstood as 150 units. Also, every 12 hours. Pharmacy filled pre- The patient did not take any of the the pharmacist did not call to clarify scription as tacrolimus 0.5 mg/mL, medication. the prescription with the provider and [take] 2 mL (1 mg) by mistake. notified the social worker that the pre- Two prescriptions were presented to The patient was prescribed Lantus® staff—one for the husband and one scription could only be partially filled [insulin glargine] 70 units subcutane- due to limited stock. for the wife. The husband was sup- ous at bedtime as prescribed. The posed to get citalopram and his wife The pharmacist who was checking label and instructions were incorrectly was supposed to get metoprolol. The reports noticed an error [involving listed as 30 units at bedtime. The wife received both prescriptions in Lisinopril-hydroCHLOROthiazide] patient has not required additional her name. She said she took one of that perpetuated for 10 months. The care or medication. No current lab the citalopram since her name was physician’s office was contacted and work in computer system. on it. Verified with the wife that she since the patient was doing well, the The patient’s mother called nursing only took one dose. Incorrectly labeled decision was made to keep the dose as for refill of medication [topiramate]. bottle was brought back by the it had been dispensed and taken by It was then discovered that the patient and replacement was given to the patient. patient had been dispensed the wrong her. The patient’s only complaint was dosage and patient had been receiving that she was lightheaded and dizzy Wrong Dose/Under Dosage wrong dose [for 3 days]. and that her blood pressure was a Under dosing was identified in 10.2% little elevated that day. (n = 106) of the events. In 40.6% (n = 43) Wrong Patient The patient received medication of the errors, the selected strength was Wrong patient errors comprised only prescribed for another patient. The half the prescribed strength. Incorrect 8.4% (n = 88) of all events. Of these patient did not read label and took drug strength was cited in 42.5% (n = 45) errors, 90.9% (n = 80) reached the the medication for three months. of the errors, 10.4% (n = 11) had incorrect Page 58 Pennsylvania Patient Safety Advisory Vol. 14, No. 2—June 2017 ©2017 Pennsylvania Patient Safety Authority DISCUSSION Wrong drug and wrong dose errors brand name now Trintellix®) was retrieved There are many differences between occurred during both the order entry from the pharmacy shelf instead of inpatient and outpatient pharmacies. An and production stages of the dispensing Brilinta® (ticagrelor), an antiplatelet agent. inpatient pharmacist may fill orders for process. Order entry is the stage in which The two drugs were stored side by side, medications, monitor patient medication the prescription details are entered or and the wrong product was selected. The therapies, provide drug information, and selected in the pharmacy computer sys- patient fell and was admitted to a hospital prepare infusions. Outpatient pharma- tem. Findings from other error reporting with a periorbital hematoma after taking cists provide many similar services (e.g., programs are similar to those identified Brintellix for nine days.8 In another event, filling prescriptions, educating patients, in the events submitted to the Authority. the incorrect strength of ARIPiprazole, administering immunizations, providing For example, in one event, methotrexate, an antipsychotic, was nearly dispensed to medication therapy management, calling a high-alert medication (i.e., a medication the patient. The bottles of ARIPiprazole doctor’s offices to get refills or clarify pre- that bears a heightened risk of harm if 2 mg and ARIPiprazole 5 mg, both from scriptions) but are also tasked with calling used in error), was incorrectly selected the same manufacturer, looked alike with insurance companies for reimbursement, in the computer system instead of meto- similar size, shape, color, and labeling. completing transactions with customers lazone, a diuretic. The patient took the Additionally, the strength of each product at the point of sale, completing business medication daily for one week until she was displayed in a small font size on the reviews, and running a business. developed mouth ulcers.6 In a second far right edge of the main panel of the example, a wrong dose error was reported label and could be missed if the bottle was The quantity of medication dispensed of after a patient brought in a new prescrip- turned slightly.9 any given prescription is different between tion for oxyCODONE 5 mg. To expedite outpatient and inpatient pharmacies. Analysts identified that 8.4% (Figure 1) the dispensing process, the pharmacist of the events submitted to the Authority While inpatient pharmacies typically pro- copied the patient’s previous oxyCO- vide one day’s worth of medications for a DONE 30 mg prescription. However, he were wrong patient errors; however, given patient in the hospital, in the outpa- failed to edit the product dose strength, this error might be more common than tient setting, 30- and occasionally 90-day indicated. A study conducted by the leading to the patient receiving the wrong Institute for Safe Medication Practices prescriptions are dispensed. Also, errors dose. The same pharmacist conducted (e.g., wrong drug, wrong strength) that (ISMP) found that a correctly filled pre- the final verification immediately after scription was given to the wrong patient occur in the hospital setting have more completing order entry and filling the opportunities to be caught by other prac- at the point of sale once for every 1,000 prescription, limiting the effectiveness of prescriptions.10,11 With close to 4 billion titioners before reaching the patient than the check.7 Ideally, one person (e.g., phar- in the outpatient setting. Outpatient dis- prescriptions dispensed each year, an aver- macy intern, pharmacy technician, second age of seven wrong patient errors happens pensing errors frequently reach patients, pharmacist) performs data entry for the who may fail to notice their prescription is prescription, allowing the verification each month at every pharmacy across the not what it should be. In 12.7% (n = 33 United States. This number does not take pharmacist to perform a truly indepen- into account a person getting the wrong of 259) of the wrong doses, both over and dent double check. under dose, reports noted that patients medication because the wrong patient’s took at least one dose of a medication Analysts identified events in which the name was chosen when entering the that was not the correct strength or wrong drug or wrong strength of a medi- prescription into the computer system. amount. Of these reports, 81.8% (n = 27 cation was selected from the pharmacy In addition to the potential harm from of 33) of the patients took at least one shelf during the production stage of the receiving another patient’s medications full month of the incorrect strength, and dispensing process. The production stage (e.g., administration of a contraindicated the error was found upon refill. In fact, of the pharmacy workflow includes activi- medication, omission of the correct 48.5% (n = 16 of 33) of patients were ties such as retrieving the drug stock bottle medication, misuse of the incorrectly dis- reported to have taken the incorrect from the pharmacy shelves, counting out pensed medication), a wrong patient error strength for multiple months. For the the number of tablets to be dispensed, can result in a breach of protected health wrong drug errors, 17.6% (n = 36 of 205) and applying the computer-generated information.10 of patients who received the wrong drug prescription label to the prescription Wrong patient errors occur for several took at least one dose of the medication, container. Similar medication errors have reasons. First, a mistake may be made with 36.1% (n = 13 of 36) of the patients been repeatedly detailed in the literature. when one patient’s medication is acci- taking at least one month’s worth. For example, an error occurred when the dently placed in another patient’s bag antidepressant Brintellix (vortioxetine, Vol. 14, No. 2—June 2017 Pennsylvania Patient Safety Advisory Page 59 ©2017 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S for pickup.10 Another way a correctly a patient received a three-cycle supply of Although automation can increase the filled medication can be given to a wrong lomustine, a chemotherapeutic agent, efficiency of the dispensing process, it can patient is when pharmacy staff selects from a mail-order pharmacy.14 However, also be involved in errors. There were sev- the wrong patient’s bag from the will call the patient was to take one cycle’s worth eral events submitted to the Authority in area and bypasses recommended ways of medication and then be reevaluated. which look- or sound-alike drugs contrib- of verifying a patient’s identity, such as To dispense the correct dose of lomustine uted to wrong drug errors with the use of using two patient identifiers.10 Failing to 150 mg, the pharmacy sent three separate automation. For example, in one report, use two patient identifiers also reduces prescription bottles, one with 100 mg the traMADol cell or bin in the phar- the likelihood that a pharmacy technician capsules, one with 40 mg capsules, and macy robot was refilled incorrectly with or pharmacist will catch wrong patient one with 10 mg capsules with the instruc- traZODone. When wrong drug errors errors that occurred when entering the tions to take a dose from each bottle for involving automation occur, the error can prescription into the computer system. a “total of 150 mg daily once per month occur multiple times over the course of Considering that only half of patients as directed.” The patient, who did not days, impacting multiple patients, until confirm their name on a prescription receive counseling from the pharmacy, the error is discovered. This type of error, label, and only about three-quarters con- took the entire three-cycle (9 capsules) which can also include filling the cell with firm the medication’s name prior to use, supply and died 6 weeks later. A major the incorrect drug strength, has also been this can result in a patient taking another contributing factor to the event was that reported in the literature. For example, a patient’s medication.12 the pharmacy sent enough capsules for pharmacy technician inadvertently loaded one cell in a robot with two different med- Another issue that predominantly affects three cycles of therapy instead of just one. ications.16 It was thought that she only the outpatient setting is the practice of An article published December 2016 in scanned the first bottle of medication she delivering prescriptions to the patient’s the Chicago Tribune highlighted the poten- added to the cell and skipped scanning home or location by courier or mail. tial shortcomings of current drug-drug the second bottle, which was a different Although delivery services can offer con- interaction screening processes.15 For the medication. The patient discovered that venience and help ensure homebound article, reporters presented prescriptions the prescription vial contained two differ- patients receive their medications, there with known contraindications to con- ent medications and reported the error are potential failure modes that could comitant use (e.g., a chronic cholesterol before the mistake caused any harm. impact patient safety. The first issue is the medication and an acute care antibiotic) inability to accomplish verification using and recorded the number of times interac- LIMITATIONS two patient identifiers if the patient is not tion was missed. Among the community In-depth analysis by the Authority of home or if the prescription is delivered pharmacies presented with these prescrip- events involving hospital and health- by a commercial courier or through the tions, the interaction was missed between system outpatient pharmacies is limited mail. This may lead to a patient getting 30% and 72% of the time. What makes by the information reported through another person’s medication, an error this worrisome is that in each encounter, PA-PSRS, including the event descrip- identified in 35.4% of the wrong patient the prescriptions were filled at the same tions. As with all reporting systems, the dispensing errors that involved delivery pharmacy. The rate of missed interac- type and number of reports collected services. A second risk with home delivery tions and therapeutic duplications are depend on the degree to which facil- is the decreased likelihood that the phar- likely to only be higher if the patient is ity reporting is accurate and complete. macist provides education to the patient. filling prescriptions at different, unrelated Although the narrative fields of the Although a medication-information insert pharmacies with non-interfaced computer reports help analysts discern what hap- may be delivered to the patient with the systems (e.g., two different retail pharmacy pened during the event, they often do not prescription, the pharmacist is not imme- companies, a mail order pharmacy and contain details describing how the event diately available to provide direct patient a local independent pharmacy). Access deviated from the standard operation, the counseling. The pharmacist must take to the patient’s inpatient and outpatient specific stage of the pharmacy workflow steps to contact and convey important medical record, which some hospital and process in which the error occurred, or medication information to the patient by health system outpatient pharmacies have, which factors contributed to the event. It telephone.13 If the medication has com- can help the pharmacists obtain a fuller is important to note that these reports are plex instructions for use or has dangerous picture of the patient’s health history and from outpatient pharmacies affiliated with side effects, this barrier to patient educa- identify potential drug-related problem hospitals or health systems and the results tion can prove dangerous to the patient. interactions and duplications. of this study may not apply to other types This was the case in one event in which of pharmacies. Page 60 Pennsylvania Patient Safety Advisory Vol. 14, No. 2—June 2017 ©2017 Pennsylvania Patient Safety Authority RISK REDUCTION STRATEGIES are selected during order entry.10 If the data entry against the prescrip- One of the most important differences applicable, use a patient’s middle tion rather than the vial, to guard between the inpatient and outpatient initial to differentiate patients with against confirmation bias. pharmacy is the opportunity to intercept the same first and last name in the —— For refills, check the scanned image errors. Unlike inpatient settings, once an system. Use modifiers such as Jr. and of the original prescription, and error occurs in an outpatient pharmacy, Sr. when applicable.17 verify the prescription is being dis- fewer healthcare practitioners handle the —— When searching for a drug in the pensed correctly.21 medication and can possibly intercept pharmacy computer system during —— Enlist clinical staff to report inappro- the error before it reaches the patient. order entry, type the drug name priate or irrelevant alerts. An expert The final dispensed prescription is in using the first four or five letters committee within the organization the control of the patient rather than a and its strength.18 Instruct pharmacy can review questionable or frequently nurse or healthcare practitioner, as in an staff to not first retrieve the medica- overridden alerts, recommending inpatient setting. Patients who do not tion stock bottle from storage and system customizations and providing notice an error in their prescription may then scan the product’s barcode as a feedback to database providers.22 continue to take the incorrect medication means to enter (or select) the drug in —— Educate pharmacists on using the until either the pharmacy notices the the pharmacy computer system. If the clinical decisions support (CDS) error upon refill, or the patient experi- wrong product is selected from stor- tools available in the pharmacy ences a treatment failure or other harm. age at order entry, there will be no computer system. CDS tools are This means that outpatient pharmacies opportunity to catch a potential drug intended to support rather than and other stakeholders need to critically selection error later in the dispensing replace the clinical judgment of the evaluate the systems in place, identify process by scanning the barcode. pharmacist.22 opportunities for improvement, and implement high-leverage risk reduction Production Point of Sale strategies. The reality that the patient —— Take the drug monograph or phar- —— Ask the patient to provide at least is the final line of defense against error macy label to the shelf to get the two patient identifiers, including also means that outpatient pharmacies drug and verify the National Drug their full name and date of birth, must engage patients to help identify Code (NDC) on the label matches when picking up prescriptions.10,11 and catch mistakes. Consider the strate- the NDC on the bottle. Return drug This is important for all patients, gies described below, which are based stock bottles to shelves immediately even those well known to pharmacy on a review of current literature, events after filling the prescription to avoid staff. Compare the patient-provided reported to the Authority, and observa- crowding the work counter. identifiers to the information in the tions from the ISMP. —— Implement barcode scanning to computer system or on the prescrip- identify when the wrong product is tion receipt. Triage and Order Entry selected from the shelf.19,20 Review —— Employ technological solutions —— Establish a policy that requires collec- compliance with barcode scanning to help ensure verification of the tion and use of the patient’s date of to ensure staff complies with this patient’s identity. One possibility birth when the prescription is pre- safety step.19 is to build a blind prompt into the sented to pharmacy staff and when —— Require scanning of each stock bottle point-of-sale computer system that selecting a patient in the pharmacy or package (e.g., inhaler, insulin car- requires the pharmacy staff member computer system. ton) when more than one stock bottle to ask for the patient’s date of birth —— For prescriptions that are phoned or package is needed to fill a prescrip- and then key punch it into the reg- to the pharmacy, use preprinted tion or a cell in a dispensing robot.16 ister.10 If the date of birth does not prescription phone pads that prompt match the patient’s profile or is not the receiver to ask the caller for date Verification entered, the transaction cannot be of birth, allergies, and purpose of —— Use the original prescription or completed. the drug. an image of the original prescrip- —— Open the prescription bag and —— Flag patients with similar names tion when conducting verification have the patient review the in the computer system so that an and medication utilization review. pharmacy labels and contents of alert will appear when these patients Encourage the pharmacist to check each prescription container to Vol. 14, No. 2—June 2017 Pennsylvania Patient Safety Advisory Page 61 ©2017 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S verify that the medication is pharmacist with any concerns lettering [see https://www.ismp. correct.10,11 The use of a will call or questions.10,13 For high-alert org/tools/tallmanletters.pdf]) system that employs clear plastic drugs or drugs with potentially to help staff identify look-alike hanging bags to hold prescrip- harmful side effects, particularly medications or medication tion containers and receipts if it is the first time the patient pairs that have been involved in awaiting pick up can facilitate is receiving the medication, dispensing errors. this process. consider proactively calling the patient to review important Quality Processes — Provide patient education.10,11 Include a discussion of the information to reduce the risk — Have pharmacy managers or medication’s purpose to help of misuse. medication safety officers peri- ensure the correct medication is odically perform quality-control Storage checks by observing the process being dispensed to the correct patient. When analyzing the — Ensure stickers, labels, or at the different phases of the events reported to the Author- markings do not obscure the dispensing process, including ity, it appeared that many could manufacturer’s barcode.26 the point of sale, to ensure have been caught if patient Review inventories periodically adherence to standardized work counseling had taken place. to check that manufacturer’s practices.10,13 barcodes are not covered up. — Proactively conduct compre- — Employ scripted patient educa- tion and checklists, especially — Face labels forward when bot- hensive safety assessments of for high-alert medications, tles are stored on the shelf. the systems in place in the to aid in educating patients — For look-alike products, explore pharmacy. One tool that can and to promote consistent ordering one of the medications help pharmacies evaluate their discussions.6,23 from a different manufac- current systems is the free turer.20 Also, avoid labels that 2017 Institute for Safe Medica- — If the medication is being used separate the strength from the tion Practices Medication Safety off label, ensure that the patient product name.9 A good refer- Self Assessment® for Community/ understands why their doc- ence to check for container Ambulatory Pharmacy.27 tor chose this medication for them.24,25 label appearance is DailyMed, — Develop and operate a con- a service provided by the U.S. tinuous quality improvement — Avoid asking a “yes” or “no” National Library of Medicine (CQI) program to enhance question when verifying the (http://dailymed.nlm.nih.gov/ patient safety, identifying and patient’s identity (e.g., by read- dailymed/index.cfm). evaluating quality-related events ing aloud the patient’s date of — Ensure look- and sound-alike and constantly enhancing the birth) or when providing patient names and packaging are suf- efficiency and effectiveness of education.10,13 Ask the person to ficiently separated, regardless of the structures and processes that supply the information so that normal alphabetical placement. determine the outcomes of med- you can confirm it. When asked Inform staff of the reasons for ication dispensing and use.27 “yes” or “no” questions, patients may answer “yes” and confirm relocating these problematic — Work with hospital or health- the information presented drugs. Provide signage to direct system information technology was correct, only to take home staff to the storage site for relo- staff and health information someone else’s medication. cated medications.20 technology vendors to establish — Use shelf dividers to keep stock access to the inpatient medical — If a friend or family member separated and neatly organized health record. Access to the is picking up the patient’s pre- on shelves. patient’s full medical health scription or it is delivered to the — Add shelf talkers (a product record better enables the patient’s location, send instruc- or sign designed to call atten- pharmacist to perform a full tions for the patient to open tion to products on a shelf) at medication reconciliation and the package at home, check the specific storage locations or use screening for interactions and contents before taking any of other strategies (e.g., Tall Man duplications. the medication, and call the Page 62 Pennsylvania Patient Safety Advisory Vol. 14, No. 2—June 2017 ©2017 Pennsylvania Patient Safety Authority CONCLUSION (n = 587) of reported outpatient make certain that patients are receiv- With an estimated 64 million medica- medication errors reached the patient. ing the correct therapy. Educating and tion errors occurring each year in the Outpatient pharmacies provide the last empowering patients to engage in patient outpatient setting and an average of 87 opportunity for a healthcare professional counseling can prepare them to serve as outpatient medication errors reported to to intervene to ensure patients receive and the final barrier in preventing errors from the Authority annually, the chance of a take the correct medication in the correct negatively impacting themselves and help serious error harming a patient is a real manner. By reviewing patients’ medica- ensure that they are getting the therapy possibility. In Pennsylvania 56.2% tions upon each fill and providing patient they need. counseling, outpatient pharmacists can NOTES 1. Flynn EA, Barker KN, Carnahan BJ. 10. Open the bag to catch errors at the point- 20. Look-alike bottles. ISMP Med Saf Alert National observational study of prescrip- of-sale. ISMP Med Saf Alert Com/Amb. Com/Amb. 2017 Jan;16(1):2-3. tion dispensing accuracy and safety in 50 2015 Jul;14(7):1-3. 21. Always verify the original prescription pharmacies. J Am Pharm Assoc (Wash). 11. Cohen MR, Smetzer JL, Westphal JE, when dispensing refills. ISMP Med Saf 2003 Mar-Apr;43(2):191-200. PMID: Comden SC, Horn DM. Risk mod- Alert Com/Amb. 2011 Feb;10(2):2. 12688437. els to improve safety of dispensing 22. Reynolds JL, Rupp MT. Improving 2. Total number of retail prescription drugs high-alert medications in community clinical decision support in pharmacy: filled at pharmacies (2015). [internet]. pharmacies. J Am Pharm Assoc. 2012 Sep- toward the perfect DUR alert. J Manag Menlo Park (CA): Henry J. Kaiser Family Oct;52(5):584-602. Also available: http:// Care Spec Pharm. 2017;23(1):38-43. Also Foundation; [accessed 2017 Feb 20]. Avail- dx.doi.org/10.1331/JAPhA.2012.10145. available: http://www.jmcp.org/DOI/ able: http://kff.org/other/state-indicator/ PMID: 23023839. abs/10.18553/JMCP.2017.23.1.38. total-retail-rx-drugs/?currentTimeframe=0. 12. Trettin KW, Narus E. Chapter 47. Imple- 23. Opioid safety. ISMP Med Saf Alert Acute 3. Szeinbach S, Seoane-Vazquez E, Parekh A, mentation of a VA patient-centered Care. 2014 Mar;13(5):1. Herderick M. Dispensing errors in com- prescription label. In: Duffy VG, editor. 24. Safety briefs. ISMP Med Saf Alert Com/ munity pharmacy: perceived influence of Advances in Human Aspects of Health- Amb. 2002 Oct;1(2):1. sociotechnical factors. Int J Qual Health care. Boca Raton (FL): CRC Press; 2012. Care. 2007 Aug;19(4):203-9. Also avail- p. 429-38. 25. Safety briefs. ISMP Med Saf Alert Com/ able: http://dx.doi.org/10.1093/intqhc/ Amb. 2003 May;2(4):2-3. 13. Avoiding wrong-patient errors at the mzm018. PMID: 17567597. point-of-sale. ISMP Med Saf Alert Com/ 26. Don’t cover manufacturer’s barcode. 4. Institute for Safe Medication Practices Amb. 2011 Feb;10(2):1-3. ISMP Med Saf Alert Com/Amb. 2015 (ISMP). Root cause analysis workbook for Nov;14(1):1. 14. With oral chemotherapy, we simply must community/ambulatory pharmacy. Hor- do better. ISMP Med Saf Alert Com/ 27. Institute for Safe Medication Practices sham (PA): Institute for Safe Medication Amb. 2014 Jul;13(7):1-4. Also available: (ISMP). 2017 Institute for Safe Mediation Practices (ISMP); 67 p. Also available: http://www.ismp.org/Newsletters/ Practices medication safety self assessment http://www.ismp.org/tools/rca/RCA- ambulatory/showarticle.aspx?id=8. for community/ambulatory pharmacy. Complete.pdf. Horsham (PA): Institute for Safe 15. Roe S, Long R, King K. Pharmacies miss 5. NCC MERP index for categorizing Medication Practices (ISMP); 2017. 35 half of dangerous drug combinations. medication errors. National Coordinating p. Also available: http://www.ismp.org/ Chicago Trib 2016 Dec 15. Also available: Council for Medication Error Reporting selfassessments/Community/2017/2017_ http://www.chicagotribune.com/news/ and Prevention; 2001. 1 p. Also available: ISMP_CommunityAmbulatory_ watchdog/druginteractions/ct-drug-inter- http://www.nccmerp.org/sites/default/ Pharmacy_Self_Assessment.pdf. actions-pharmacy-met-20161214-story.html. files/indexColor2001-06-12.pdf. 16. Robot workaround. ISMP Med Saf Alert 6. Methotrexate-metolazone mix-ups. Com/Amb. 2011 Aug;10(8):2. ISMP Med Saf Alert Com/Amb. 2016 17. Oops, sorry, wrong patient! A patient Jun;15(5):1-2. verification process is needed everywhere, 7. Risk when copying old prescriptions. not just at the bedside. ISMP Med Saf ISMP Med Saf Alert Com/Amb. 2015 Alert Acute Care. 2011 Mar 10;16(5):1-5. Jun;14(6):1-2. 18. Institute for Safe Medication Practices. 8. Name change needed to prevent more Look-alike generic names. ISMP Med Saf Brintellix-Brilinta mix-ups. ISMP Med Saf Alert Acute Care. 2016 Nov;21(22):3-4. Alert Com/Amb. 2015 Aug;14(8):1-2. 19. Do not let “Depo-” medications be a 9. Label characteristic contributes to errors. depot for mistakes. ISMP Med Saf Alert ISMP Med Saf Alert Com/Amb. 2016 Com/Amb.2016 Mar;15(3):1-4. Jan;15(1):3-4. Vol. 14, No. 2—June 2017 Pennsylvania Patient Safety Advisory Page 63 ©2017 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 14, No. 2—June 2017. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2017 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. This publication is disseminated via e-mail. To subscribe, go to http://visitor.constantcontact.com/ d.jsp?m=1103390819542&p=oi. To see other articles or issues of the Advisory, visit our website at http://patientsafety.pa.gov. THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS The Pennsylvania Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (“Mcare”) Act. Consistent with Act 13, ECRI Institute, as contractor for the Authority, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the Pennsylvania Patient Safety Authority, see the Authority’s website at http://patientsafety.pa.gov. ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for nearly 40 years, ECRI Institute marries experience and independence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology. The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP’s efforts are built on a nonpunitive approach and systems-based solutions. Scan this code with your mobile device’s QR reader to subscribe to receive the Advisory for free.