Dispensing errors can either make you or break you!

I say this because when I was an intern pharmacist, I had my first experience with a dispensing error, which was a turning point in my career. It really shaped the kind of pharmacist I became. It scared the hell out of me, and almost made me quit, but with reflection, self-awareness and building good checking techniques and processes I overcame it.

What are dispensing errors?

Dispensing errors and near misses are sometimes used interchangeably but they really are completely different aspects.

A near miss is an error caught at the 'checking point' of the prescription, an error that was 'nearly missed'.

A dispensing error is an error that has passed the 'check point', and is now with the patient. In other words, it is out of your control to amend it!

What happened?

So to be honest, I was a careless intern when it came to dispensing.

I believe I took the process lightly without understanding the real consequences of what may result if I dispense the wrong medicine.

I don't think it was intentional, but my problem is that under the stress of the workload and the environment I was in, I used to rush.

In addition, I think knowing that someone else is checking after me, and catching anything that will fall through the gaps gave me reassurance that I can get it wrong, and the checking pharmacist will hopefully catch it.

TERRIBLE way to think, as I found following this incident 👇👇

So it was a busy day in the dispensary, the regular pharmacist (owner) was on holiday there was a locum, and it was just the two of us. It was the perfect recipe for disaster really - an incompetent intern, a locum pharmacist & a rush hour!

We received a prescription for a patient for Doxepin, it was entered correctly by me, then when it came to dispensing, I dispensed Dothiepin instead of Doxepin...

A common error in my time, except it wasn't caught by the charge pharmacist and was handed over to the patient.

What happened afterwards...

The patient came a couple of days later...

I was familiar with this patient (as we all are in community pharmacy). She approached me and was incredibly polite for the situation (for which I was thankful)..

"I just want to check if this is the medication I have been getting. It looks different and I have been feeling awkward on it like I am on a high.."

Without even holding the box, I saw it across the counter and I felt a sense of doom...my whole career was crumbling in front of my eyes... my heart missed beats as if I was facing an execution fate.

Shakingly, I took the box and went to the locum pharmacist, who was just as nervous. We got the script out, confirmed an error had happened, changed it to the right medicine & followed the process for openly disclosing to the patient what happened.

Thankfully, the patient was grateful (and so was I) that it wasn't an error of a greater magnitude. She thanked us for openly discussing it with her and for giving her an opportunity to complain which she declined (phew!).

We documented the incident, exploring where things could have gone wrong to ensure this doesn't happen again.

Whose fault was it?

Mine. I took total accountability for how careless I was as I elaborated above.

The moment you blame others for not catching your mistakes is the moment you're telling yourself "it ain't my fault" and you'll continue to make them.

What did I learn from it?

Well, it stopped me from making another error, or even a near miss for the rest of my career. I can hardly even remember making any near misses, after that incident.

I went home and despite being shattered by the incident, I did some serious reflection..

At the front of my PSNZ intern folder, there was a checking process mnemonic created by a pharmacist called John Fraser, called the PHARMSI check. It literally saved me, I only wished I had looked at it earlier on in my internship.

It is a fool-proof process for checking prescriptions, if you follow it religiously, you will not make any mistakes. It was my recipe for not making a single mistake ever again, here it is:

When you receive a prescription

1 - Check legality > signature & date

2 - Check PHARMSI

P - Patient details > correct patient, NHI, address, DOB

H - How to take > directions, dose, dose frequency

A - Amount total = correct quantity

R - Route = correct dose form

M - Medicine = Correct Drug and Name

S - Strength = correct strength

I - Interactions = clinical check of drug-drug & drug-condition interactions & suitability in the patient's context

I can confidently say it made me an 'invincible' dispenser & checker!

The other thing it taught is to separate any similar-sounding medicines on the shelves with highlighted prompts like "Are you sure this is the one you want?"

Final words

Dispense as if no one is checking after you!

Change your mindset to dispensing being a final process, rather than relying on someone checking to pick up your mistakes...

My first dispensing error when I started in pharmacy

Dispensing errors can either make you or break you! I say this because when I was an inter

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