As a newly qualified pharmacist, you will soon develop your own style in checking prescriptions while following the Standard Operating Procedures (SOPs) in whatever pharmacy setting you find yourself.
I would recommend that all pharmacists remember the 4 P’s method when checking prescriptions:
1. Patience. This is key as so many near misses and dispensing incidents occur when not enough time is spent in concentrating on the prescription in front of the pharmacist. Distractions like phone calls, requests to see pharmacists, and questions from other staff members can all contribute. Do not be afraid to tell people you will attend to them when you have finished the prescription at hand.
2. Patient. The very first thing to look out for in a prescription is the name, address, and age (or date of birth) of the patient. This prepares you for assessing the actual prescription based on if the patient is under 12 (extra dosage checks for all prescriptions) or over.
3. Prescription. Once you have confirmed the prescription is valid (signature and valid date) you can now concentrate on the body of the prescription by checking clinically for appropriate dose, indication, and any controlled drug prescription requirements are satisfied.
4. Product. In addition to getting the right directions and dosage as required by the prescription and confirmed by your clinical checks ensuring the right product (right drug, right form, right strength, right quantity) has been dispensed and checked is the crucial part of checking.
It is important to realise that dispensing incidents likely to cause most harm to patients may be the ones where the totally Wrong product (medicine) has been dispensed and wrongly checked.
A typical example of this will take us to the issue of what I term PRoblem drugs. Historically, some serious dispensing incidents have involved medicines beginning with PR. The prime example is PRopranolol being dispensed on a prescription that calls for PRednisolone. It is easy in the cold light of day without the conditions at the time of dispensing/checking to wonder how this could happen but it does.
Imagine a prescription that calls for, PRednisolone 5mg tablets, taken eight tablets once every morning, and this label is placed on boxes of PRopranolol 10/40/80 mg tablets and the patient ends up taking 80mg/320mg/640mg as a single dose.
It is important to check the product against the prescription and not against any label.
Some pharmacists use the ‘tick’ system so for the above example:
1. Prednisolone, tick ‘Prednisolone’ on the box of PRednisolone
2. 5mg, tick ‘5mg’ on the box of PREDnisolone 5mg
3. Tablets, tick ‘tablets’ on the box of PREDnisolone 5mg tablets
4. 28, tick or circle ‘28’ on the box of 28 PREDnisolone 5mg tablets.
The idea behind this is if you are unable to tick what is on the prescription your mind immediately asks you why. For example, you want to tick 5mg and you are confronted with 10mg (e.g. PRopranolol 10mg) on the box and you immediately pause.
The same thing applies to ticking ‘tablets’ if you are confronted with ‘capsules’ on the box or ticking or circling ‘28’ if you are confronted with ‘56’ on the box.
Dispensing incidents are not very common in pharmacy as a percentage of the millions of items are checked annually. However, near misses are more common, hence the importance of recording and learning from every near miss.
If you are ever unfortunately involved in a dispensing incident, it is important to initially stay calm but respond in an appropriate time frame depending on the circumstances.
In an example where a patient has collected medication that the pharmacy team somehow discovers is incorrect, the first thing is to try to contact the patient by phone straight away. If contact is not possible, depending on the level of dispensing incident attempt to visit the patient’s home either by staff member/delivery driver or yourself. The urgency will be determined by the potential harm to patient. So a PRopranolol/PRednisolone mix-up like above would require urgent resolution and a case of capsules given instead of tablets might not be as urgent.
The best outcome is if the incorrect medication is retrieved from the patient before they have taken any. An apology should be offered at the same time as re-dispensing the correct product and ensuring the patient is informed a full report would be made and procedures put in place to prevent further recurrences.
A dispensing incident report should be completed, ensuring you follow the SOP for the pharmacy you work in and any other requirements. For example, additional controlled drugs notifications, etc., and your indemnity insurer informed. If the patient has taken one or more doses of the wrong medication, then you should assist them obtain medical advice and ensure their GPs are informed.
Finally, as newly qualified pharmacists, do not in any way be anxious about being involved in a dispensing incident as they are rare so, go out there, be patient, and offer a good professional service to your patients. I am wishing you all the best and a long, exciting pharmacy career.
By Bayo Adegbite, locum community pharmacist and PDA Union South East England Regional Committee Member
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