Sunday, November 27, 2011

Dispensing Errors

The last think any pharmacist wants is to be accused of being reckless -

Suffice it to say that I've worked in almost all aspects of pharmacy (except nuclear pharmacy), and in innumerable pharmacies, throughout my career - and I've seen everything. I can't tell you how many times my ass was put on the line because someone accused me of committing a dispensing error.

Many pharmacists won't admit it, but anyone who's been a pharmacist for any length of time has probably committed a dispensing error, can tell you just how easy it is to make a dispensing error, and can describe how the daily pressures of pharmacy operations could lead to potential errors.

No matter how much we don't like it or want it to happen, dispensing errors can be reduced, but never fully eliminated as long as human are involved. But, experience has also shown me that pharmacists often get blamed for dispensing errors that didn't actually occur.

I can't tell you how many times an investigation proved that an elderly patient, a family member, or a caretaker added multiple prescriptions into one vial for ease of use, mistakenly switched medication vials while filling a daily dispensing package, or changed vials just because of personal preference - after the prescription left the pharmacy.

I also can't tell you how many times I've had drug abusers bring back a vials to the pharmacy labeled hydrocodone/APAP that contained amoxicillin instead, saying that I gave them the wrong medication; or just how many times I've had a family-member picking up grandma's pain medication call to tell me there was thirty tablets missing, even after my back-count shows that I filled it accurately.

So although I hate to admit it, in all of the places that I've worked, the technology and robotics used by the highly-automated PBM mail-order pharmacies are the best that I've experienced in reducing dispensing error rates AND drug-seeking schemes. It nips these problems right in the butt.

The reason is because their robotics take a picture of the medicine inside of the prescription vial as it is being dispensed. This technology provides an invaluable service to the pharmacist. These pictures are then filed into the computer system with the prescription information for verification and recording purposes. Having a picture of the dispensed drug on file serves as proof of what was dispensed. Like the saying goes, a picture is worth a thousand words.

Now, if only the chains could fully incorporate this type of technology into retail pharmacy practice.


  1. Great post. Technology aiding in pharmacist verification is great. From personal experience, human factors is still the rate limiting step. Unfortunately, we've had techs mix in wrong tablets into the filling stock used by the machine. A vial may only have 1 erroneous tab in the bottom of the vial where the picture doesn't capture it. Of course, the RPh must do their due diligence.

  2. Hi! nice post. Well what can I say is that these is an interesting and very informative topic. Thanks for sharing.Cheers!

    - The dispensing guns

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