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Patient Safety Tip
of the Week
August
31, 2021
The
Community Pharmacy and Patient Safety
One
venue weve largely ignored in our many columns on patient safety over the
years is the community pharmacy. We have discussed how community pharmacies are
often left out of the loop when medications are discontinued, often leading to
unintended dispensing of those medications (see columns listed below). And weve
noted a few other examples where patients were given the wrong medications at
their pharmacy. But perhaps because we lack a dedicated data repository for
errors related to community pharmacies, we have little knowledge of the scope
of patient safety issues related to them.
Frankly, were surprised we havent heard more about
patient safety events related to community pharmacies. All you have to do is stand in a long line at a community
pharmacy and watch the pharmacists and assistants taking phone calls and
incoming orders and scrambling to get all their prescriptions filled and
dispensed to patients. In that hectic and stressful environment, wed expect
errors to occur. Tradeoffs between safety and efficiency have been a topic of
many of our columns (see, for example, our Patient Safety Tip of the Week ETTOs:
Efficiency-Thoroughness Trade-Offs).
ISMP Canada (ISMP Canada 2021) saw the same vulnerabilities and recently
published a bulletin on balancing safety and efficiency in the community
pharmacy.
ISMP
Canada queried several databases over roughly 2 years and identified 192
incidents related to community pharmacies, 94 of which were included in their
final analysis. They identified 6 areas where measures intended to expedite
prescription processing contributed to medication incidents in 3 phases of the
medication process:
- Prescription order entry
- Prescription filling
- Prescription pickup
Under
prescription order entry the old copy and paste error appeared, just
as we have often seen it in errors related to other facets of the electronic
medical record. The example given is where the pharmacist copies a previous
prescription for the same medication, with the intention of editing it to
include the new information (such as a dose change or frequency change). The
staff member then overlooks changing the intended information and the patient
is dispensed the wrong prescription. ISMP Canada notes that the safe practice
is to create a new entry for all new prescriptions and limit the copy function
to new prescriptions that are unchanged from the previous prescription in the
patients profile.
A
second theme under prescription order entry relates to delay in patient profile
updates. For example, in their hurry to dispense a change in previously
used medication or a new medication for the same problem, a pharmacist may fail
to delete the old medication from the patient profile. This may result in the discontinued
prescriptions remaining on the profile, possibly leading to duplicate therapy or
other error. (That is similar to the issue we have
previously raised where a clinician discontinues a medication but that never
gets conveyed to the community pharmacy and the discontinued medication remains
on the patients active medication profile.)
Under prescription filling, one of the errors is related to
a workaronnd we have seen in hospitals repeat
scanning of bar codes on one item to represent multiple items. For example,
this might involve scanning the bar code on 1 item multiple times, rather than
scanning the bar code on each item separately, when more than 1 package of a
medication is needed to fill a single prescription. An example is provided
where one of 3 items had a different dosage that was missed because only the
first item was scanned 3 times.
And
perhaps the biggest drawback in the busy community pharmacy is failure to
take time to counsel patients who are picking up their prescriptions. ISMP
Canada notes that the pharmacy IT systems often show alerts that could or
should be discussed with patients, but the busy pharmacist often does not take
the time to do so. Or someone other than the patient is picking up the
medication so there is no opportunity for discussion.
For
the former problem, ISMP Canada suggests the pharmacist should identify and
document discussion points during the verification process and attach the documentation
to the filled prescription as an alert for the pharmacist to engage in patient
dialogue before the prescription is released. For the latter, it suggests use
of technology to communicate with those patients not picking up the medication
themselves.
Difficulty
finding workers, both professional and non-professional is a major problem. In
a recent survey of independent community pharmacists (NCPA 2021), 80 percent said they are having a
difficult time filling open positions. Nearly 90 percent of respondents say
they cant find pharmacy technicians and nearly 60 percent cant find front-end
employees to run the cash register, track inventory, and manage other basic
store operations. More than 13 percent are having difficulty trying to hire
staff pharmacists to handle prescriptions and patients.
Weve
for years said that the community pharmacist is the most underutilized
component of our healthcare system. If you think about it, the community
pharmacist is often the healthcare professional with the most frequent
opportunities to interact with our patients. Many patients still go to their
pharmacy monthly (though mail order has changed this considerably). So, aside
from medication counselling, things like blood pressure monitoring and many
preventive services could be delivered during those visits to the pharmacy.
Its
high time that health policy makers consider how to make better use of these
valuable assets.
Some of our other columns on failed
discontinuation of medications:
May 27, 2014 A Gap in ePrescribing: Stopping Medications
March 2017
Yes! Another Voice for Medication
e-Discontinuation!
February 2018 10 Years on the Wrong Medication
August 28, 2018 Thought You Discontinued That Medication?
Think Again
December 18, 2018 Great Recommendations for e-Prescribing
August
2019 Including Indications for Medications: We Are
Failing
August
6, 2019 Repeat Adverse Drug Events
Some of our other columns on medication
errors:
December
2007 1000-fold Heparin Overdoses Back in the News
Again
May
2008 UK NPSA Alert on Heparin Flushes
July 15, 2008
Heparin
Flushes.....Again!
March 24, 2009 Medication
Errors in the OR
May 20, 2014 Ophthalmology:
Blue Dye Mixup
September 2014 Another
Blue Dye Eye Mixup
November 3, 2015 Medication Errors in the OR - Part 2
December 1, 2015 TALLman Lettering:
Does It Work?
May 2016 Name Confusion in the Pharmacy
May 24, 2016 Texting Orders Is It Really Safe?
July 2016 ISMP Updates TALLman
Lettering List
August 23, 2016 ISMP Canada: Automation Bias and Automation
Complacency
December 2016
Standardize 4 Safety and Just Bag It!
March 2017
Loading Doses Again
March 2017
Yes! Another Voice for Medication
e-Discontinuation!
June 2017 Just Bag It Campaign Success Story
August 2017 Medication Errors Outside of Healthcare
Facilities
September 2017 Safe Medication Use in the ICU
January 2018 Eliminating Vincristine Administration Events
February 2018 10 Years on the Wrong Medication
May 8, 2018 Heparin Overdose
August 28, 2018 Thought You Discontinued That Medication?
Think Again
September 2018 ISMP Updates List of High-Alert Medications
December 4, 2018 Dont Use Syringes for Topical Products
December 11, 2018 Another NMBA Accident
December 18, 2018 Great Recommendations for e-Prescribing
January 1, 2019 More on Automated Dispensing Cabinet (ADC)
Safety
February 5, 2019 Flaws in Our Medication Safety Technologies
February 12, 2019 From Tragedy to Travesty of Justice
March 5, 2019 Infusion Pump Problems
April 2019 ISMP on Designing Effective Warnings
June 11, 2019 ISMPs
Grissinger on Overreliance on Technology
July
9, 2019 Spinal
Injection of Tranexamic Acid
August
2019 Including Indications for Medications: We Are
Failing
August
6, 2019 Repeat Adverse Drug Events
November
19, 2019 An
Astonishing Gap in Medication Safety
February
4, 2020 Drugs
and Chronic Kidney Disease
May
2020 PPSA on IV Vancomycin Safety
June
16, 2020 Tracking
Technologies
July
2020 Medication Dosage Miscalculations
July
21, 2020 Is
This Patient Allergic to Penicillin?
August
4, 2020 Intravenous
Issues
April
27, 2921 Errors
Common During Thrombolysis for Acute Ischemic Stroke
References:
ISMP Canada (Institute for Safe Medication
Practices Canada). Balancing Safety and Efficiency in Community Pharmacy. ISMP
Canada Safety Bulletin 2021; 21(7): June 30, 2021
https://www.ismp-canada.org/download/safetyBulletins/2021/ISMPCSB2021-i7-Safety-Efficiency.pdf
NCPA
(National Community Pharmacists Association). Tight Labor Market Squeezing
Local Pharmacies, Survey Shows. NCPA Press Release June 2, 2021
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