Dispensing errors can happen to anyone

Dispensing errors can have an enormous impact on both the customer and the pharmacist.  Imagine how you would feel if a simple mistake caused serious harm to someone?   Unfortunately, we see firsthand how distressing these events can be.

It may seem unnecessary or over the top, to have a step by step dispensing procedure in your pharmacy.  After all, dispensing is at the very heart of what it means to be a pharmacist.  You do it every day and you’ve developed your own routine.  It works for you – you don’t make mistakes. 

Yet dispensing errors reported to Guild Insurance tell a different story.  They remind us that mistakes happen every day.  Pharmacists are increasingly under pressure.  Customers can be impatient if asked to wait for more than a few minutes.  There are frequent interruptions during dispensing and pharmacists are expected to make greater efficiencies in tough financial times.  Gaining customer loyalty is also a daily challenge due to fierce competition.  As such, many pharmacies are carrying a wider range of stock to cater to different needs.  Needless to say, pharmacists are experiencing unprecedented workload pressures.  Coupled with fatigue and personal stresses, the risk of making a serious dispensing error cannot be ignored.  It really can happen to you.

Getting into the habit of following a thorough, systematic dispensing procedure for every script can help protect you against an unthinkable error.  Developing a good routine reduces your reliance on simply being vigilant, particularly when you are tired or working long hours.  It helps reduce the chance of human error.  However, it does take time for a set routine to become second nature.  Success requires commitment to following the same steps every time, even when processing the easiest of scripts.  The more you get into a habit, the easier it should become. Furthermore, it also helps you to identify barriers and improvements to dispensing practices.  Sometimes, we don’t realise that our workflows are inefficient and adding to our difficulties until a serious error happens.   

Despite this, some pharmacists still believe that risk reduction strategies, such as barcode scanning, can place unrealistic demands on their already busy workloads; “It slows me down at the very time I need to be more efficient”.  However, embedding safe dispensing practices before an error or crisis occurs can lead to greater efficiencies.  But it does take some planning and teamwork.

Reducing the risk of dispensing errors

  • Evaluate your current dispensing practices.Are you doing everything you can to reduce the risk of error?Are you using accepted risk reduction strategies such as barcode scanning?If not, why not?
  • Work with others in your pharmacy to agree on a step by step dispensing procedure.Refer to the PDL ‘Guide to good dispensing’.
  • Gain the commitment of every pharmacist to follow the procedure every time.If the pharmacy owner and senior staff don’t follow the procedure, then no one else will.
  • Periodically review the procedure to identify better, safer ways of doing things.
  • Display posters or reminders in the dispensary to promote compliance with procedures.
  • Review dispensing workflows.Are there any barriers to good dispensing, such as poor directional workflow resulting in double handling or confusion?
  • Use the safety features available in your dispensing software.Set up different alerts to remind people to perform certain tasks.Likewise, make use of advanced scanning features that automatically print a barcode on the dispensing label.
  • Work with the pharmacy owner to review the effectiveness of barcode scanners.Are they working properly?If they are difficult to use or unreliable, is it any wonder a pharmacist may be reluctant to use them.Similarly, has everyone had adequate training on how to use the scanners most effectively?For example, what’s the best way to label and scan small products such as creams and eye drops?
  • Review how medication stocks are managed.Separate high-risk medications.Educate the staff unpacking stock about why it can be dangerous to store medications in strict alphabetical order or by manufacturer grouping.Empower them to come up with further ideas for reducing selection errors.
  • Work with all staff to help reduce distractions and interruptions while pharmacists are dispensing.Encourage individual retail staff or pharmacy assistants to lead this change.Consider using simple signage alerting people not to interrupt a pharmacist who is dispensing.
  • When handing medications to a customer, point out all warnings and directions on the label and packaging.This not only helps with counselling but serves as a final check against any dispensing error.
  • Finally, seek help if you are having trouble adhering to safe dispensing practices in your pharmacy. PDL members can access confidential guidance and support by telephoning – 1300 854 838.Likewise, PGA members may contact their state branch via www.guild.org.au
Dispensing Errors Can Happen To Anyone


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