Patients beware: Ways to minimize medication errors

Pharmacists and patients should communicate with each other about prescriptions to avoid errors.

Issue: November 2007

ByRhonda Cooper-DeHoff, PharmD

As part of the biennial requirement for pharmacy license renewal in the State of Florida, I recently took a mandatory two-hour continuing education course in medication error prevention.

While I was looking forward to this course about as much as having a tooth pulled, what I learned from this course and subsequent research compelled me to dedicate this month’s column to the topic of medication errors and ways to empower patients to catch and prevent them before it is too late.

The public has long rated trust in their pharmacist very highly, often rating them as more trusted than clergymen or physicians. Yet, year after year, serious and sometimes deadly medication dispensing errors occur, usually unbeknownst to patients or their physicians.

Rhonda Cooper-DeHoff, PharmD, MS, FAHA
Rhonda Cooper-DeHoff

Points to consider

Last year in the United States, almost 4 billion prescriptions were filled by community and mail-order pharmacies. With the recent implementation of Medicare Part D prescribing benefits and the aging and oft unhealthy lifestyle of the American people, that number will steadily climb.

There are many places during the prescription process that errors can occur, beginning when the prescription is written and culminating when the prescription is handed over to the patient. Many studies have documented error rates at each step along the way, and although many of these studies have limitations related to methodology, there are some important points to consider:

Cognitive review of the prescription by a pharmacist prevents most prescribing errors from ever reaching a patient, including incorrect medicine, strength or quantity for indication, and potential therapeutic duplication and/or interaction with other medications the patient may be taking.
Dispensing errors, defined as a discrepancy between what was correctly prescribed and what was given to the patient, occur with varying degrees of seriousness.
In a recent study evaluating 4,481 prescriptions filled in 50 community pharmacies (chain, independent or health system affiliated) in six major U.S. cities, 77 errors were noted, and only 13 of the 50 pharmacies had 100% accuracy for prescriptions filled during the observation period. Of the errors observed, 6.5% were judged clinically important. The most frequent type of error was wrong label instructions, but there were also errors in the categories of wrong quantity, wrong strength, wrong drug, and omission of information deemed important. Most errors occurred in pharmacies without robotics or other technologies designed to minimize errors, and the majority of errors were associated with new, rather than refill, prescriptions.
Based on the total number of prescriptions filled per year, the authors estimate as many as 51 million medication dispensing errors occur annually and 3.3 million of these may be serious. Per year, an individual patient has a one in 30 chance of being exposed to a dispensing error and a one in 1,000 chance that error could be serious.

Several studies performed more recently confirm these findings.

Advice for patients

Patients are rarely encouraged to understand the contents of their prescription before leaving the doctor’s office and to verify their prescription before leaving the pharmacy.

There are many reasons these errors occur, including look-alike and sound-alike medication names, use of error prone abbreviations, illegible handwriting, poor physical pharmacy environment, reliance on technical support staff, inadequate pharmacist staffing, distracting work conditions, prescription volume and fatigue, just to name a few. Almost a decade ago, the Institute of Medicine heightened awareness of patient exposure to human error, and now we readily recognize the potential harm to patients from scenarios like wrong-site-surgery, incorrect diagnosis and lack of practice and/or institution experience with a procedure. As a result, patients are now instructed to mark the correct site with a big “X” prior to surgery, to get a second opinion and are encouraged to search the Internet for data related to experience at a given institution before undergoing any risky procedure.

But patients are rarely encouraged to first, understand the contents of their prescription before leaving the doctors office and, second, verify their prescription before leaving the pharmacy.

One way to prevent prescribing errors is for a medical practice to utilize electronic medical record software that includes a module designed to electronically transmit prescriptions to a pharmacy and that provides a printed record that can be handed to the patient for verification purposes at the time of prescription pick-up. This limits the possibility of prescribing errors due to the menu-driven nature of most software packages and eliminates the potential for errors related to transcription or illegible handwriting.

Prior to leaving the doctor’s office with a new prescription, patients should be told:

What the name of the medication is.
Why it is being prescribed.
What the dose is and how often it should be taken.
What the common side effects are.
What the important drug and/or food interactions are.

When picking up a prescription, patients should ask these same questions of the pharmacist in order to confirm that the patient is receiving the intended medication at the intended dose. Patients should pop the lid of prescription bottle before leaving the pharmacy, which provides the patient and the pharmacist an opportunity to do a final visual check of the contents and opens up the opportunity for dialogue. If it is a refill prescription and the contents look different than the last time the prescription was filled, patients should inquire why it is difficult.

Polypharmacy is now commonplace, particularly in cardiology practices where patients with hypertension, atrial fibrillation, diabetes, arthritis, atherosclerosis and many other disorders are routine. Therefore, patients should be reminded to get all of their prescriptions filled at the same pharmacy, which increases the likelihood that drug-drug interactions and therapeutic duplications will be caught.

For more information:

Rhonda Cooper-DeHoff, PharmD, MS, FAHA, is Assistant Director of Clinical Programs and Research Assistant Professor in the Division of Cardiology at University of Florida College of Medicine, Gainesville. She is a member of the Cardiovascular Pharmacology Section of the Cardiology Today Editorial Board.
Flynn EA, Barker KN, Carnahan BJ. National observational study of prescription dispensing accuracy and safety in 50 pharmacies. J Am Pharm Assoc (Wash). 2003;43:191-200.
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Knudsen P, Herborg H, Mortensen AR, et al. Preventing medication errors in community pharmacy: root-cause analysis of transcription errors. Qual Saf Health Care. 2007;16:285-290.
Szeinbach S, Seoane-Vazquez E, Parekh A, Herderick M. Dispensing errors in community pharmacy: Perceived influence of sociotechnical factors. Int J Qual Health Care. 2007;19:203-209.
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