MEDICATION

SAFETY AND ROLE

OF PHARMACIST
 MEDICAL ERROR & MEDICATION ERROR

A medical error is any circumstance, action, inaction, or

decision related to health care that contributes to an unintended
health result.
Medication error are among the more common types of medical
errors.

Medication errors include administering or prescribing the

wrong drug, providing the wrong dose, or using the wrong route
to administer drugs to patients.
 MEDICATION ERROR

According to IOM (Institute of Medicine), only in

USA, about 7000 people die annually due to
medication error
400,000 are affected or injured due to drug error
Lives are lost, patient are disabled or lose valuable
time from work or school
It is pharmacist responsibility to ensure medication
safety but it requires extensive knowledge
 WHICH TYPE OF KNOWLEDE IS REQUIRED

PASTO
PISTOL
L

The mistake was catched because it was already

learnt and memorized
 WHICH TYPE OF KNOWLEDGE IS REQUIRED

Similarly for finding medication error, it

requires extensive knowledge of:
Pharmacology
Pharmacognosy
Pharmaceutics
Alternative Medicines
 PRESCRIPTION FILLING PROCESS FOR
COMMUNITY AND HOSPITAL PHARMACY
PRACTICE
Step 1 : Receive and Review prescription
Step 2: Enter prescription into computer
Step 3: Perform DUR and resolve
medication issue
Step 4: Generate prescription label
Step 5: Retrieve medication
Step 6: Compound or fill prescription
Step 7: Obtain a pharmacist review and
approval
Step 8: Store completed prescription
Step 9: Deliver medication to patient
 PRESCRIPTION FILLING PROCESS FOR
COMMUNITY AND HOSPITAL PHARMACY
PRACTICE

Although it looks a long

procedure but Safety cant be
compromised for speed, lest a
medication error more likely will
result.
Name: Saif Ali S/O Ali Hassan
Gender: Male
Age: 36
Working: Pharmacist/Analyst Rx
Address: P-360, Medina Colony
FSD Tab. Atorvastatin 5mg
Contact: 0334-8496556 BID af. cib. Refills: 4
Allergy:
Complain:Penicillin drugs
Chest pain Mitte: 10

Diagnosis: Hypertension, High

LDL
Dr. Ahmer (FCPS, MBBS, MD)
People colony, FSD
0321-4908354
Practioner # PMC-2002-23
8 th
March, 2017
DEA # MP26466844 16:30:52
 STEP 1: RECEIVE AND REVIEW PRESCRIPTION

POTENTIAL
INFORMATION TO RESOURCES TO ERRORS DUE TO
CHECK VERIFY FAILURE TO CHECK
OR VERIFY

Physician
Legibility
Pharmacist Prescription
(clear to
Nurse misread
read)
Patient
 STEP 1: (CONT.)

POTENTIAL
INFORMATION TO RESOURCES TO ERRORS DUE TO
CHECK VERIFY FAILURE TO CHECK
OR VERIFY
Prescriber
Biodata Invalid Prescription
Name filled
Physician Fraudulent
Signature
Pharmacist prescription filled
Address Nurse Patient receives
Contact number medication
Registration number intended for
DEA number (for another patient
narcotic prescription)
 STEP 1 (CONT)

POTENTIAL
INFORMATION TO RESOURCES TO ERRORS DUE TO
CHECK VERIFY FAILURE TO CHECK
OR VERIFY
Patient Biodata Physician
Pharmacist
Name
Age/DOB
Nurse Incorrect patient
Patient selected
Sex
Address Immediate contraindicated
Contact family drug dispensed
Diagnosis/conditio member
n
Allergy (if any)
 STEP 1 (CONT)

POTENTIAL
INFORMATION TO RESOURCES TO ERRORS DUE TO
CHECK VERIFY FAILURE TO CHECK
OR VERIFY
Medication
Information Physician Wrong medication
Drug Name Nurse dispensed
Dose Patient Profile Wrong formulation
Dosage form Family member dispensed
Route of administration Wrong dose dispensed
Refills Patient administers
Directions for use incorrectly
Dosing schedule Outdated prescription
Date
 FAMILIAR EXAMPLES IN ERROR IN REVIEWING
PRESCRIPTION

Syrup of aspirin-incompatible-irritate GIT

Antibiotic dispensed to patient after 4 months of infection
(healthy now)
Dose of Pediatric chalk is not suitable

A patient given Diclofenac acid IV-but it was actually for IM

Electronically signed-but not acceptable

 FAMILIAR CASE OF ERROR IN REVIEWING
PRESCRIPTION

A technician, on a telephone call from a nurse,

misheard Pamelor (antidepressant) for Tambocor
(Antiarrhythmic).
The error was not discovered upto a month.
Fortunately, the patient experienced no adverse
effects.
It can be prevented by E-prescribing and reviewing
profile.
 STEP 2: ENTER PRESCRIPTION INTO COMPUTER

POTENTIAL
INFORMATION TO RESOURCES TO ERRORS DUE TO
CHECK VERIFY FAILURE TO CHECK
OR VERIFY
Look
Cross check alike/sound
Data choices from brands/generi
computer menu alike drug
are same as on cs selection
prescription error
Spelling on
prescription match
with drug selected
 STEP 2 (CONT)

POTENTIAL
INFORMATION TO RESOURCES TO ERRORS DUE TO
CHECK VERIFY FAILURE TO CHECK
OR VERIFY
Cross check
measure
dose selected match prescribed drug
with prescription with choices listed

Patient given
Cross check dose written
incorrect dose
with available strength on
Dose having dose having selection menu
zeros Cross check decimals or
Check decimal leading/trailing zeros
 STEP 2 (CONT)

POTENTIAL
INFORMATION TO RESOURCES TO ERRORS DUE TO
CHECK VERIFY FAILURE TO CHECK
OR VERIFY

Available forms Physician

Inappropriate
match the Pharmacist
formulation
route/formulati Formulary
selection
on selected
FAMILIAR EXAMPLES IN ERROR DURING ENTRY
INTO COMPUTER

In Pakistan, Oxidil (Ceftriaxone), has two

forms and varied doses like 250mg, 500mg
and for IM and IV on same brand name so
error may occur while selecting

Prescription of 3.5ml Amoxicillin syrup but

pharmacist misleadingly enter 3.5
teaspoonfuls-advised to enter in milimeters
STEP 3: PERFORM DRUG UTILIZATION REVIEW
AND RESOLVE MEDICATION ISSUES
 STEP 3 (CONT)

POTENTIAL
INFORMATION TO RESOURCES TO ERRORS DUE TO
CHECK VERIFY FAILURE TO CHECK
OR VERIFY
Pediatric Dosing
(Prescribed dose
and frequency of Original
Serious overdose
dosing on a prescription
Pediatric specialist Adverse reactions
pediatric patient Package inserts Side effects
consistent with Pharmacist Treatment failure
manufacturer
recommendations
and pharmacy
references)
STEP 3 (CONT)
 STEP 3 (CONT.)

Incorrect dose of medication in Geriatrics and Pediatrics

patients can cause severe Adverse Drug Events
because they have poorly developed mechanism.
In other cases, the drug may be contraindicated,
allergic or causing adverse effect

So NO TEARS tool is used for medication review

 STEP 3 (CONT.)

NO
TEARS

N O T E A R S

Risk
Evidence Simplificat
Need and Open Tests and Adverse reduction
and ion and
indication Question Monitoring events and
guidelines switches
prevention
STEP 3 (CONT.)
STEP 3 (CONT.)
STEP 3 (CONT.)
 PRODUCT NAME (PF) 00.00 mL/g/mg/ng NDC:032586-AL
Ingredients:
Active Pharmaceutical Batch#
Ingredients only for Should be understandable
official preparation License#
APIs+excipients for 515-GCUF

Pharmacist: Dr. Haroon

unofficial preparations Registration#

Physician: Dr. Ahmer

Pharmacy: GCUF 515
Directions: PHARM 515
Take 00mL TWO times a day Date of Dispensing:

Patient: Saif Ali

Storage:
Store at room temperature Expiry Date:
away from heat and Discard after from date of
moisture dispensing
Precautions: Price:
Shake well before use 99/-
STEP 4: GENERATE PRESCRIPTION LABEL
STEP 4 (CONT)
 STEP 4 (CONT)

POTENTIAL
INFORMATION TO RESOURCES TO ERRORS DUE TO
CHECK VERIFY FAILURE TO CHECK
OR VERIFY

Compare
Wrong
label with
Formulation formulatio
prescripti
n
on
 STEP 4 (CONT)

POTENTIAL
INFORMATION TO RESOURCES TO ERRORS DUE TO
CHECK VERIFY FAILURE TO CHECK
OR VERIFY
Other data elements
Brand/generic name
NDC number
Manufacturers name Incorrect
Patient name Physician medication
Physician Electronic dispensed
Pharmacist name and database Medication
signature Prescription dispensed to
Batch number incorrect patient
License number Medication is
Registration number invalid or illegal
Discard date Expired medication
Manufacture/dispense date may be used
STEP 5: RETRIEVE MEDICATION
 FAMILIAR CASE

CASE: Troppi vs. Scarf

Pharmacist accidentally dispensed Nardil
(Antidepressant) instead of Norinyl (Contraceptive).
The woman who received the incorrect drug gave birth
to a child.
Michnigan Court of Appeals held the pharmacist liable
not only for the medical expenses incurred in the
womans pregnancy but also for the costs of raising the
child.
STEP 6: COMPOUND OR FILL PRESCRIPTION
 STEP 6 (CONT.)

During compounding, pharmacist-ensure-calculations are correct

Ingredients-weighed accurately
Sterility and hygiene-maintained

SOPs should be observed very carefully

Filling-ensure packing suitable for product

Paste label on container-label language should be according to patient

STEP 7: OBTAIN A PHARMACIST REVIEW AND
APPROVAL
 STEP 7: OBTAIN A PHARMACIST REVIEW AND
APPROVAL

POTENTIAL
INFORMATION TO RESOURCES TO ERRORS DUE TO
CHECK VERIFY FAILURE TO CHECK
OR VERIFY

Review
Label
prepared Original Wrong
medication prescription medication
/take review Stock medication dispensed
label Incorrect dose
of senior Calculation
pharmacist
STEP 7 (CONT.)
STEP 8: STORE COMPLETED PRESCRIPTION
 STEP 8: STORE COMPLETED PRESCRIPTION

POTENTIAL
INFORMATION TO RESOURCES TO ERRORS DUE TO
CHECK VERIFY FAILURE TO CHECK
OR VERIFY

Patient medication is Physical review of

separated adequately bags, boxes or bins

Medication dispensed
Use of organization to incorrect patient
system
Storage area is neat Bins, boxes, bags,
and orderly alphabetizing,
numbering,
consolidation
STEP 9: DELIVEER MEDICATION TO PATIENT
 STEP 9: DELIVEER MEDICATION TO PATIENT

POTENTIAL
INFORMATION TO RESOURCES TO ERRORS DUE TO
CHECK VERIFY FAILURE TO CHECK
OR VERIFY
Patient or Administration
caregiver Pharmacist error
understand the Drug Drug
instructions information interaction
Directions resources Adverse
Dosage Original reactions
Discard prescription Degradation of
Precautions medication
Storage
STEP 9 (CONT)
 STEP 9 (CONT.)

Show and tell technique-to educate the

patient-show product and use gestures to
tell how to use
Pharmacist responsibility-make patient
aware of his/her condition
If patient can become depressive after
telling about his/her situation-pharmacist
must avoid it
The End
Thanks to all of you
WITH PROFOUND REGARDS