The PCC considered a number of complaints that related to dispensing errors and highlighted:
- that pharmacists should be extra vigilant in making sure that the dosage instructions on the dispensing label reflect the information on the prescription and when dealing with medicines which have a narrow therapeutic index;
- the importance of pharmacists having a robust checking procedure in place for the supply of all prescription medicines;
- the importance of good stock management and suitable storage arrangements in minimising the risk of dispensing errors, especially where medicines have different strengths, similar packaging or similar sounding names;
- that where a dispensing error does occur, it is important to put in place suitable remedial actions to minimise the risk of a similar error occurring again.
Key Learning Points for Pharmacists
1. The superintendent and supervising pharmacist should take time to consider the inherent risks in their pharmacy and put in place procedures and staff training to help minimise the risk of dispensing errors occurring.
2. A robust dispensing and checking procedure should be in place in your pharmacy which is consistently followed. Where at all possible, this should involve at least two people to help to minimise the risk of human error, and the pharmacist must always carry out a final check between the label, the medicinal product and the prescription.
3. Careful consideration should be given to where medicines are kept in the dispensary being mindful of the potential for picking errors, for example medicines that can be easily confused due to their name or packaging should be separated where possible. Alerts on the shelf edge or computer can also help remind pharmacists and staff members about high risk medicines or those with a narrow therapeutic index.
4. Errors and near misses should always be reported and recorded, and the staff members involved informed of the error. All errors and near misses should be regularly reviewed and used to identify staff training and/or amend practice, policies and procedures, to minimise the risk of a similar incident happening again.