A nurse called a patient's pharmacy to order a prescription for the diuretic metolazone. The pharmacy technician taking the order was new, had not received any formal training, and previously worked in the store's floral department before being transferred to the pharmacy. When transcribing the prescription, the technician made the error of writing down once-daily methotrexate instead of metolazone. The pharmacist didn't catch the once-daily methotrexate dose (typically dosed once a week, unless it's being used for cancer), and the computer system did not flag the dosing schedule either. When the patient's husband came in to pick up the prescription, he was asked if he had any questions, to which he answered "no." No additional education was provided. The patient used the medication daily as directed on the prescription label, and one month later she died from the effects of drug [1].

"The single greatest impediment to error prevention in the medical industry is that we punish people for making mistakes."

-- Dr. Lucian Leape, Professor, Harvard School of Public Health [5]

National organizations that work to find ways to improve patient safety through prevention of medication errors include:

How do you define medication errors? What is your pharmacy's policy and procedure for handling medication errors? Why is it important to be able to define and recognize medication errors?

FDA has a collaborative Safe Use Initiative which has a goal of reducing preventable harm by identifying specific, preventable medication risks and developing, implementing, and evaluating interventions with partners who are committed to safe medication use [8]. The targets of this initiative are wide ranging. Examples of current projects include the following topics [9]:

Health Canada and ISMP Canada have partnered to create the Canadian Medication Incident Reporting and Prevention System (CMIRPS) [10]. This is a consumer-based website providing information on using medications safely.

Medication Safety Best Practices

Pharmacists should always write legibly, check allergies, and review patients’ drug profiles for potential interactions. When appropriate, ask about liver and kidney function.

Pharmacy technicians should always write legibly, check allergies, and not automatically override interaction alerts.

Medication errors can include [14]:

What specific errors have you witnessed and what were the weaknesses in the medication use process that contributed to the error? How did the errors affect patients, family, and pharmacy staff?

Legal claims can give us clues as to which medication errors may be most common. Nearly two-thirds of all legal claims against pharmacists involve dispensing the wrong drug (42%) or wrong dose (22%). About 7.5% of legal claims against pharmacists are due to errors involving the wrong patient. Errors caused by failure to counsel with the prescribing practitioner make up about 5% of legal claims and calculation or preparation errors make up about 3% [17].

How many of your prescriptions received are electronic versus written? How is e-prescribing safer than handwritten prescriptions? What are the risks of e-prescribing?

Which dangerous abbreviations do you still see used? What errors have you seen in your own practice caused by abbreviations? How do you discourage the use of dangerous abbreviations by prescribers?

John received a handwritten prescription from Dr. Le one busy Monday morning. As he usually found with Dr. Le's prescriptions, it was not clearly written. But Dr. Le commonly prescribed metronidazole so he was pretty confident in his interpretation. He read and dispensed the prescription as metronidazole 1,000 mg, give two doses two weeks apart. However, Dr. Le had actually written for mebendazole 100 mg, give as two doses two weeks apart.

What examples of look-alike/sound-alike medication errors have you encountered? What was done to help prevent the same error from occurring again?

FDA and Health Canada review all medication names prior to marketing. In the US, a process of using simulated prescriptions and computerized models is used to determine if a brand name may be confused with products that have already been approved [36]. If the proposed brand name is found to be unacceptable due to the potential for medication errors, FDA will reject it [36].

Despite attempts to prevent drug name confusion, there have been times when FDA approves a drug name that is later found to cause issues in real world practice. In some cases, FDA will work with manufacturers to change previously approved brand names after they've already come to market. Below are a couple examples of this:

Does your pharmacy computer system use "TALL man" lettering? Where do you see this lettering used? How have you found it helpful for distinguishing between look-alike drugs?

A sound-alike error was the cause of a fatal mix-up between the drugs naloxone and Lanoxin. A patient who needed naloxone for respiratory depression from morphine instead got two ampules of Lanoxin (digoxin; used for treatment of congestive heart failure and atrial fibrillation) and subsequently died. This error may have been prevented if the person taking the order would have repeated it back to the prescriber or had the prescriber spell the drug name [41].

Different salt forms of a drug can also be a source of confusion when looking at a drug name. For example, a prescription for immediate-release metoprolol tartrate given once daily (which should normally be given twice daily), or a prescription for the long-acting metoprolol succinate given twice daily (which should normally be given just once daily) should be questioned. These drugs may sometimes be dosed in this manner, but it's always a good idea to confirm.

Consider workarounds or shortcuts that you or colleagues use in your work setting. Why are they used? What are the possible risks of these workarounds or shortcuts? How can the system be changed to eliminate these potentially at-risk behaviors?

Which medication alerts require pharmacist review in your pharmacy? Why do these alerts require review and what are the consequences of bypassing these alerts?

What steps has your pharmacy taken to reduce alert fatigue? How many alerts are automatically overridden in your pharmacy? What dangers do you see with alert fatigue?

One strategy to decrease interactions is to streamline a patient's drug list. Look for duplicate or unneeded meds that may be able to be discontinued.

What conditions in your pharmacy do you find most distracting? What have you done to help yourself maintain your focus and reduce distractions while working?

What is verbal order read-back and why is it so important for helping to prevent errors?

Do you use verbal order read-back appropriately? What types of errors have you caught with verbal order read-back? How do you encourage prescribers or other staff to be patient with this double-check process?

What methods do you use to effectively communicate with patients? What kinds of questions can you ask your patients to initiate conversations?

Pharmacists can use these steps to help identify barriers and increase adherence when counseling patients:

Which medications are at high risk of being involved in medication errors that result in serious harm? What policies and procedures, if any, does your pharmacy have around their handling and use of high-alert medications?

Let's review a couple specific examples of high-alert drugs or drug classes:

Is it illegal to prescribe or dispense against a boxed warning?

No. It isn't illegal. But your liability risk can increase. A contraindication means that the risk of using a drug in a particular situation generally outweighs the therapeutic benefit. A boxed warning is not always a contraindication. The box is to highlight serious risks, such respiratory depression with the combination of opioids and benzodiazepines, antidepressants and suicidality, NSAIDs and the risk for cardiovascular events, ACE inhibitors and the risk of fetal injury/death, etc..

Pharmacists should evaluate whether a drug with a boxed warning applies to their patient and compare the risks to the benefits. Look for ways to monitor for early signs of adverse events and involve the patient in decision making where appropriate. Make sure you have strong justification to dispense any contraindicated drug.

Some outpatient pharmacies audit new prescriptions, usually within a day or two after they were filled. Having a second set of eyes check an Rx against what was entered into the computer can help catch errors. And if the audit is done soon enough, any errors might even be caught before the patient picks up the prescription.

ISMP and other experts say that the informed patient is a key ingredient of medication safety [69].

What questions do patients who have been recently discharged from the hospital ask? How do you help patients reconcile their medications and reduce the risk of medication errors during transitions of care (e.g., from hospital to home, from a rehab facility to home)?

When gathering medication histories, it's important to find out about a patient's OTC and natural product use to provide complete profiles. Don't forget to ask about allergies (including drugs, foods, dyes, latex, etc.) and vaccinations that the patient has received.

Have you ever been involved in a significant medication error? What led to the error and what could you have done differently? How have you changed your practice based on this error?

What is your pharmacy's policy for reporting medication errors and near misses? What is the first step that should be taken when a potential medication error is reported?

If your organization utilizes a PSO, keep in mind that the information collected by a PSO is privileged. The data they collect has certain confidentiality protections. Communications with PSOs are protected to allay fears of increased risk of liability. The information reported to a PSO may not be used in criminal, civil, administrative, or disciplinary proceedings. The goal of PSOs is to improve the quality of patient care and safety.

Have you ever been involved in a root cause analysis or failure mode and effects analysis (FMEA)? If so, what did you learn? Did you feel the process was effective? How did it change your practice?