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Patient Safety Tip of the Week

August 31, 2021

The Community Pharmacy and Patient Safety



One venue we’ve 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 we’ve 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, we’re surprised we haven’t 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, we’d 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 “ETTO’s: 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:


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 patient’s 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.


Another problem occurred when patients’ medications are in blister packs but there is a change in recommended dose before the next blister packs are dispensed. ISMP Canada recommends that, when possible, the existing blister pack should be repackaged to reflect the modified regimen. Alternatively, collaborate with the prescriber to determine whether a medication change can be initiated with the next blister pack to be dispensed.


Not surprisingly, under the prescription pickup category, patient misidentification was a major concern. ISMP Canada notes pharmacies should follow strict procedures for patient identification at pickup, such as asking for 2 patient identifiers and having the patient and pharmacy staff member double check the containers in the bag together before leaving the pharmacy.


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.


All the best practices often get skipped or shortcut when the pharmacy staff is too busy. The obvious solution is better staffing for community pharmacies. Economic factors and workforce issues undoubtedly contribute to understaffing. Ironically, most “pharmacies” do not make the bulk of their profits on drug dispensing (they make it on selling many items other than medications). The per prescription dispensing fees paid to pharmacies are generally very low, so payers need to reconsider their practices.


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 can’t find pharmacy technicians and nearly 60 percent can’t 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.


We’ve 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.


It’s 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       “Don’t 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              “ISMP’s 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”






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



NCPA (National Community Pharmacists Association). Tight Labor Market Squeezing Local Pharmacies, Survey Shows. NCPA Press Release June 2, 2021






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