Dispensing errors and counseling quality in 100 pharmacies

doi:10.1331/JAPhA.2009.08130

Journal of the American Pharmacists Association

Volume 49, Issue 2, March–April 2009, Pages 171-182

https://doi.org/10.1331/JAPhA.2009.08130 Get rights and content

Objective

To evaluate the dispensing accuracy and counseling provided in community chain pharmacies.

Design

Cross-sectional study.

Setting

Community chain pharmacies in large metropolitan areas of Florida, Georgia, New Jersey, and New York.

Participants

Community chain pharmacies and trained shoppers.

Interventions

Trained shoppers presented a new prescription order for one of five study drugs to each randomly selected pharmacy, and all encounters with pharmacy staff were recorded on video by ABC News 20/20 staff using hidden cameras.

Main outcome measures

Dispensing errors on prescriptions for selected medications were the indicator of prescription dispensing accuracy. Frequency of verbal counseling and information categories discussed or included in written information were used to assess the quality of counseling.

Results

Of 100 prescriptions dispensed, 22 had one or more deviation from the physician's written order, for a 22% dispensing error rate. Three of the errors were judged to be potentially harmful when dispensed to a typical patient requiring these therapies. A total of 43 shoppers (43%) received verbal counseling, including16 cases in which the shopper prompted counseling. All shoppers received written information with their prescription, covering an average of 90% of the required topics. Some 68% of the warfarin shoppers purchased aspirin without the pharmacist verbally warning about taking the drugs simultaneously.

Conclusion

The dispensing error rate of more than one in five prescriptions is similar to the rate found in a similar study conducted 14 years ago, but counseling frequency has decreased significantly during the period.

Section snippets

Objectives

The objectives of this study were to (1) determine the total number of dispensing errors on prescriptions for one of five drugs filled in a random sample of 100 community chain pharmacies, (2) evaluate the potential for patient harm of each dispensing error, (3) explore the relationship between pharmacy workload (perceived busyness) and errors, (4) determine the frequency that patients are warned about the potential drug interaction between aspirin and warfarin, (5) evaluate the frequency and

Data collection procedures

During January and February 2007, a total of 100 community chain pharmacies in Atlanta, GA; Tampa–St. Petersburg–Clearwater, FL, and New York City, NY–Newark, NJ, were randomly selected for the study. These geographic regions were selected because state law allows hidden video recording in public places. Community chain pharmacies were the population of interest because the majority of prescriptions are dispensed by community chain pharmacies. For each region, the selection of sites for

Results

Dispensing errors were identified on 22 of the 100 prescriptions (22%) at 100 pharmacies representing 10 different community chains. There were 16 wrong instruction errors (73%), 5 wrong quantity errors (23%), and 1 error in the “other” category (4%). Figure 3 displays the types of errors detected and the number of prescriptions dispensed for each medication.

All three clinicians agreed that three errors could pose a risk for patient harm: instructions on a warfarin prescription vial read, “Take

Discussion

The rate of dispensing errors was approximately the same as the rate measured 14 years ago, also using the trained-shopper method.⁷ The most notable finding was the significant decrease in the rate of counseling not stimulated by the shopper from 43% to 27% since the previous study (χ² = 3.79, P = 0.05). Possible reasons for this decrease will be presented.

No wrong drug or wrong strength errors were detected in the current study, while two wrong strength errors were detected previously.⁷ In a

Limitations

This cross-sectional study reported the prevalence of dispensing errors and counseling on a single prescription filled at a point in time for community chain pharmacies randomly selected based on market share. Results are not generalizable to all community chain pharmacies because a small number of chains (10) were selected on the basis of the greatest market share of prescriptions filled in the geographic area of interest. Prescriptions for five different drugs were used in the study, which

Conclusion

Although significant improvements in services provided by pharmacists have occurred (e.g., MTM services), data from two samples indicate that dispensing accuracy remains the same. In this random sample of 100 community chain pharmacies in four large cities, more than one in five prescriptions were dispensed in error, as was found 14 years ago.⁷ The frequency of nonstimulated verbal counseling decreased from 43% of shoppers to 27%. The number of randomly sampled pharmacists who took the

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Statistically significant differences in workplace patient safety perceptions were noted across practice setting type (p values <.001) and pharmacist roles (p values <.001). The extent to which pharmacists agreed/strongly agreed that their employer provides a work environment that allows for safe patient care ranged from 29.7% of chain community pharmacists to 85% of compounding pharmacists. Fifty-two percent of staff pharmacists, 56.5% of relief pharmacists, and 58.5% of managers/pharmacists in charge agreed or strongly agreed that their employer provides a work environment that allows for safe patient care, whereas 89.3% of regional managers/directors/vice-presidents and 72.5% of clinical/specialty pharmacists indicated the same. Average hours per shift was inversely correlated with perceptions of workplace patient safety (p values <.001).
Tennessee pharmacists' perceptions of workplace patient safety varied widely across practice setting type and pharmacist roles. Perceptions of safety were notably lower in the chain community pharmacy setting. Additional research is warranted to better understand the relationship between pharmacist perceptions and quantifiable patient safety metrics, particularly in the chain community pharmacy setting.
Impact of pharmacists’ training on oral anticoagulant counseling: A randomized controlled trial
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Short-term online oral anticoagulant counseling training improved the quality of counseling provided by community pharmacists to mystery patients on warfarin.
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Citation Excerpt :
Community pharmacies in the United States dispense over 4.1 billion prescriptions annually.5,6 Using a dispensing error rate of 3.2%, published in a previous observational studies, it may be estimated that over 131 million dispensing errors occur in community pharmacies each year.7,8 Although national error reporting systems exist, it is not well understood how often and by which methods that community pharmacy personnel address and report medication errors.9,10
Medication safety practices and methods for reporting errors in community pharmacies are relatively unknown.
(s): The primary objective of this study was to describe student-reported data on medication safety and error reporting practices in community pharmacies, and secondarily describe student learning from this assignment.
Second professional year pharmacy students enrolled at Purdue University College of Pharmacy in the United States observed and recorded medication safety and error reporting practices as part of an experiential assignment. Data were collected from 170 unique pharmacy settings between the years 2016–2018 and analyzed using descriptive statistics and a paired t-test to assess student learning.
51% of students reported documentation of 1–10 errors or near misses annually, with an additional 30% reporting 11–30. Near misses were only reported 26% of the time. Errors were most commonly reported to a pharmacy-specific reporting system (84%) and the Institute for Safe Medication Practices National Medication Errors Reporting Program (84%). The most frequently reported error types included wrong directions (34%), wrong drug (14%), wrong strength (13%), and wrong patient (12%). Pharmacists were observed to be interrupted approximately 19 times every hour. Anonymous error reporting was typically not allowed to the pharmacy's preferred error reporting system (71%). A policy requiring that the prescriber is contacted about errors was observed at 77% of the sites. The most common consequences of committing an error were education/training (72%) or progressive discipline (41%). Students reported a statistically significant increase in understanding of medication safety practices and methods for reporting errors in community pharmacies. (p < 0.01).
This data supplements existing literature on medication safety practices and error reporting in community pharmacy settings, as well as highlights knowledge gaps outside the scope of this study.
A text mining analysis of medication quality related event reports from community pharmacies
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To identify topics within the components of a proposed medication safety event framework contained in the free-text narrative of QRE reports.
A retrospective, observational analysis of data from a PSOs voluntary reporting system, from January 1, 2011 to December 31, 2014. The dataset contained structured and unstructured data elements. A structural topic model extracted themes from the free-text narrative component of the report. These topics were assigned a human label and mapped onto constructs of the medication safety event framework.
A total of 531,555 QREs were analyzed from 1660 pharmacies. 90.6% were near miss and unsafe condition reports. There were 40 topics generated. There were 29 topics identified as QRE types, 3 were identified as contributing factors, and 5 were related to signals/alerts that an incident or near miss had occurred. One topic each was identified as a recovery step and a quality improvement strategy. One topic was not assigned a human label. Examples of topics labeled included incorrect tapering directions, needing to double-check work, and attention-related contributing factor.
The free-text narrative provided novel information compared to the structured fields of the reports. Topics were mapped onto a proposed medication safety event framework to advance knowledge of medication QREs and identify ways to improve medication safety in community pharmacy. Future work may focus on communicating these topics to the pharmacies to improve medication safety efforts.
Continuous Medication Monitoring (CoMM): A foundational model to support the clinical work of community pharmacists
2018, Research in Social and Administrative Pharmacy
Citation Excerpt :
Pharmacists providing CoMM over 12 months delivered 6.8 interventions per patient on average; 3 of the interventions were patient counseling and education and 3.4 addressed drug therapy problems. In contrast, counseling that should be occurring under the distribution-focused model is not provided universally,12,13 and community pharmacists ask patients questions related to medication monitoring in only 8% of their interactions.14 Performing MTM services is an alternative response to falling product reimbursement, but missed opportunities to improve patients' medication use also can result when pharmacies limit provision of MTM services to patients eligible for third party payer reimbursement.
Under the Continuous Medication Monitoring (CoMM) approach, community pharmacists prevent, identify, resolve, and document drug therapy problems during the dispensing process.
To describe the patients receiving CoMM interventions and the pattern of delivery of CoMM interventions.
Pharmacy dispensing and clinical records were reviewed for patients filling at least one prescription and receiving at least one continuous medication monitoring intervention at a community pharmacy from April 2014 through March 2015. The proportion of patients receiving an intervention type and the number of interventions per patient were computed.
Nearly 2500 patients received 16,986 continuous medication monitoring interventions over the year. The average age of the patients receiving the interventions was 59.1 years, and they filled an average of 8.0 unique medications. An average of 6.8 interventions was delivered to each patient. About half (49.7%) of interventions addressed drug therapy problems. The pharmacists delivered 3.0 patient counseling and education and 3.4 drug therapy problem interventions per patient on average.
There are many opportunities to improve patients' medication use that can be identified and addressed under a Continuous Medication Monitoring model. Movement to this model of practice is desirable, but changes are needed to facilitate the shift.

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Disclosure: The authors declare no conflicts of interest or financial interests in any product or service mentioned in this article, including grants, employment, gifts, stock holdings or honoraria.

Acknowledgments: To those involved with data collection and Thomas Stokes, MD, for reviewing errors for clinical importance.

Funding: This study was funded by an unrestricted contract from ABC News 20/20, New York.

See related articles on pages 143 and 151.

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Special FeatureDispensing errors and counseling quality in 100 pharmacies

Objective

Design

Setting

Participants

Interventions

Main outcome measures

Results

Conclusion

Section snippets

Objectives

Data collection procedures

Results

Discussion

Limitations

Conclusion

Am Pharm

J Am Pharm Assoc

J Am Pharm Assoc

J Am Pharm Assoc

J Am Pharm Assoc

Pharmacists’ dispensing accuracy in a high-volume outpatient pharmacy service: focus on risk management

Drug Intell Clin Pharm

Illumination and errors in dispensing

Am J Hosp Pharm

Randomized trial comparing pharmacists and technicians as dispensers of prescriptions for ambulatory patients

Med Care

Accuracy of dispensing in a high-volume, hospital-based outpatient pharmacy

Am J Hosp Pharm

Dispensing errors and detection at an outpatient pharmacy

ASHP Annual Meeting

Impact of interruptions and distractions on dispensing errors in an ambulatory care pharmacy

Am J Health Syst Pharm

Dispensing error rate in a highly automated mail-service pharmacy practice

Pharmacotherapy

A field investigation of participant and environment effects on pharmacist–patient communication in community pharmacies

Med Care

Prescription accuracy: room for improvement

Med Care

Prospective study of the incidence, nature and causes of dispensing errors in community pharmacies

Pharmacoepidemiol Drug Saf

Implementation of an outpatient pharmacy dispensing error resolution team

ASHP Midyear Clinical Meeting

Special Feature
Dispensing errors and counseling quality in 100 pharmacies