Dispensing errors – wrong medication / wrong strength

Incidents involving pharmacists selecting the wrong medication or the wrong strength are the most common dispensing errors reported to Guild Insurance.  Not surprisingly, a number of these errors involve look-alike, sound-alike medications. 

Despite awareness raising campaigns, errors still occur.  While a person could suffer harm if given any medication in error, the likelihood of serious clinical effects increases significantly when the medication involved has a narrow therapeutic index.  These errors can and do happen, even to experienced pharmacists who’ve never made a mistake before.  They can happen to you and they can be fatal to your customers.

Cases

A patient was admitted to hospital with unexplained abdominal bleeding.  On investigation he was found to have an abnormally high INR, even though he had never been prescribed anticoagulant therapy.   His elevated INR was eventually attributed to a dispensing error.  The pharmacist had inadvertently made a selection error and dispensed 5mg Coumadin instead of 5 mg Coversyl as prescribed.

Due to a pharmacist’s selection error, the cytotoxic medication Hydrea was dispensed instead of the prescribed antihypertensive Hydopa.  The young woman happened to be pregnant and claimed the error resulted in her suffering a miscarriage.

A customer successfully claimed for ‘loss of income’ when she was unable to work for an extended period after a dispensing error.  Although the customer had been prescribed Lamictal 25mg, the pharmacist inadvertently dispensed 200mg tablets.  The customer subsequently took the higher dose for a number of months and suffered liver damage.  While the pharmacist said she usually used ‘barcode scanning’, she failed to do so on this occasion.

Reduce the risk of dispensing errors

  • Adhere to the PDL ‘Guide to good dispensing’ every time.Don’t be coerced into rushing or cutting corners.When errors occur, pharmacists often say “if only I’d taken the time to…”
  • Display posters or reminders in the dispensary to promote compliance with dispensing procedures.
  • Use barcode scanning every time.
  • Make use of 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.
  • Introduce measures to differentiate between look-alike or sound-alike medications:
    • Use separators, stickers or flags
    • Avoid positioning these medications in strict alphabetical order.For example, storing Coumadin under ‘W’ for Warfarin, limits the chance of inadvertently selecting Coumadin instead of Coversyl which has similar packaging.Consider storing other high-risk medications separately.
  • Promote a culture where all staff are confident to point out risky practices when they occur.
  • Seek help if you are feeling intimidated or uneasy about contacting the prescriber to clarify a script.
  • Be careful with zeros and abbreviations.Transcription or interpretation errors involving a zero, decimal point or abbreviation are common causes of serious dispensing errors.For example, 6U of insulin could easily be interpreted as 60 units.
  • Reducing distractions when a pharmacist is dispensing is everyone’s responsibility.Agree to strict rules for minimising interruptions and distractions in your pharmacy.
  • Review the dispensary layout to ensure workflow supports each step of good 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.

Download the pdf here.

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    Property maintenance - could your property cause an injury?

    Guild Insurance sees many insurance claims which have come about due to poor maintenance of a property.  In too many of these cases, the poor state of the building or its grounds is obvious and it’s quite surprising, as well as disappointing, that repairs haven’t been carried out before an incident has occurred.

    What can go wrong?

    There are a range of incidents which can occur due to poor maintenance of a property.  Staff can be injured leading to a worker’s compensation claim as well as staff being absent from work for an extended period.  Visitors to the premises, such as customers, clients or contractors, can also suffer injuries leading to public liability claims.  As well as the insurance claims which need to be managed, there’s the added stress of knowing that someone has been injured while at your premises.  Some of these injuries can be very serious and life changing.  Unfortunately, the hazards which lead to these injuries are often not viewed as seriously as they should be.  Yet with appropriate property maintenance many of these injuries could be avoided.

    Case 1

    A client entered a building and tripped over an edge of carpet which was ripped and curled up.  The client sustained a fractured wrist when they landed.

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    An awning out the front of a building was old and worn out.  During heavy winds it broke off from the building and hit a person walking past at the time.

    Case 3

    While walking through the carpark of a premises, a staff member has tripped on a large crack in the asphalt which had caused the surface to be uneven.  They fractured their ankle as they fell.

    Case 4

    Poor maintenance doesn’t just lead to people suffering injuries, it can also lead to further damage to the property.  An old deteriorating roof collapsed when hit by heavy rain as it no longer had the strength to support the weight of this rainfall.  This led to excessive water damage within the building.

    Property maintenance tips

    • Have a documented maintenance program in place. This requires a schedule for regularly checking the property to identify hazards as well as details on what needs to be serviced, repaired or replaced and when.
    • Be aware of the out-of-sight, out-of-mind hazards. Many properties have roofs, guttering and downpipes in poor condition due to a lack of maintenance as no one has thought to get up on the roof and inspect it. Include the less obvious hazards in the maintenance program.
    • Have a maintenance budget. Some maintenance work can be planned, other work will come up unexpectedly when something breaks down. You need to be able to find money to fix hazards when identified.
    • Be sure to use qualified tradespeople to undertaken maintenance work. While it can be tempting to undertake some DIY and save money, the risk of things not being maintained or repaired correctly will not be worth the savings in the long term.
    • If you’re a tenant, be aware of what you’re responsible for maintaining and what’s the responsibility of the landlord. Not all tenancy agreements are the same, so you need to be across the details of your agreement.
    • Don’t wait to undertake maintenance till a more convenient time. There are many cases of injuries occurring due to hazards which had been identified but not yet acted upon, usually due to costs, time or not acknowledging the risk of the hazard.
    • All staff have a responsibility to create and maintain a safe workspace. Some hazards will be identified through regular property inspections, however, you can’t rely solely on these inspections. Therefore, encourage all staff to continually be on the lookout for hazards and to speak up when they see something.
    • Don’t think it won’t happen to you and your property. These incidents are a lot more common that many people realise.

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    Understanding social media risks

    Social media is an ever increasing form of communication for many people in both their personal and professional lives. It presents people with many benefits in allowing them to communicate a variety of messages to many people with great speed and efficiency. However, those benefits need to be balanced with the many risks social media presents.

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    The following tips will assist individuals and businesses manage their risks when using social media.

    1. Have a business plan for how and why social media is to be used
    When deciding whether or not to create a business social media presence, it’s very easy to think ‘if everyone else is doing it, so should I’.  However there needs to be greater thought put into this decision.  The decision to use social media should be well thought out and based on a company’s needs and business plans; the benefits and risks need to be considered.

    2. Business social media should be based on business requirements, not personal views
    Business owners and managers need to be sure that when they make a decision on whether to use social media for their business, this decision is based on the needs of the organisation, not the owner’s/manager’s personal views of social media.  For example, a person who chooses to not use Twitter for personal use may still decide it’s a great tool for them professionally.  Business decisions and personal decisions regarding social media use should be separated.

    3. Create clear business guidelines and processes regarding who is able to post on social media and how this is to be done
    Due to the risks associated with social media interactions, it’s very important that businesses have a clear process for who is responsible for posting on social media.  The person undertaking this role needs to understand when social media is an appropriate form of communication and what sort of messages are to be shared using social media.  This process should also provide guidance on how often social media is monitored and responded to and how to respond to negative comments.

    4. Consider training for those staff responsible for social media
    It’s often assumed that young people are well versed in social media use however this isn’t always the case.  Also, not all users of social media understand appropriate business use and its associated risks.  Therefore it’s worth considering training in social media communications and its risks for the responsible staff members.

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    Download PDF here


    Guild Insurance Limited ABN 55 004 538 863, AFS Licence No. 233 791.  This article contains information of a general nature only, and is not intended to constitute the provision of legal advice. Guild Insurance supports your Association through the payment of referral fees for certain products or services you take out with them    .

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    How to prevent the loss of cold stock at your pharmacy

    In recent years, Guild Insurance has identified a claims trend involving the loss of cold stock in pharmacies. Over the last 2 years, we’ve seen a monumental $4 million in claims for cold stock incidents alone. Whether it’s fridges being left open,  random power outages, or plugs being disconnected for other uses, these instances can lead to a costly loss for pharmacy businesses. We’re here to help mitigate these risks and reduce your chances of facing a claim for the loss of cold stock.

    Securing cold stock more efficiently.

    Picture this: You arrive at your pharmacy early one summer morning, only to find something strange. As you step into the store away from the bustling noise outside, you’re greeted by dead silence and unusual darkness. The low whirring sound of the beverage refrigerator can’t be heard. You flick the light switch, but nothing turns on. This can only mean one thing: a power outage. Immediately, you head to the fridge and observe the temperature on the digital thermometer through the glass doors: it’s 21.5°C.

     

    You check the thermometers on the vaccine fridge too – it’s also above the recommended storage temperature. This means you can’t dispense these to customers because it’s no longer safe to do so. As you don’t have any more stock, you’ll have to turn customers towards a competitor and reschedule vaccination appointments until new medications are ordered, ultimately affecting your sales and potentially your customers’ well-being.

    What you can do

    As a result of these skyrocketing claims, policy excesses for cold stock cover are now increasing to $2,500 per claim, as a minimum.

    With that, we’ve developed several solutions to help you reduce the risk of cold stock loss and avoid the increase in excess.

    We’ve partnered with 2 leading and Gold Cross-endorsed equipment manufacturers, Liebherr and Constellation Technologies.

    Using purpose-built technology, Pharmacy Guild of Australia members can safeguard their cold stock and prepare

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    > Pharmacy vaccine refrigerators, by Liebherr

    > Uninterruptable Power Supply (UPS), also by Liebherr

    > Cold stock temperature monitoring system, by Constellation Technologies

    We strongly recommend that you purchase one or more of these or similar products for your business. In doing so, it drastically reduces your excess and could even prevent a loss from interrupting your business. Feel free to purchase other equivalent devices that suit you; if you purchase a UPS system that isn’t by Liebherr, please ensure that it has at least 8 hours of backup power supply.

    While we may not be able to stop the stress of a claim, we can help you to prevent one from occurring in the first place. Protect your business today.

    To learn more about Liebherr and Constellation Technologies and how their equipment can help lower the likelihood of a claim, visit guildne.ws/42aiTVw
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