Shopping Cart

INTRODUCTION

Medication safety is a complex responsibility that involves multiple professionals and healthcare resources. As front-line members of the medication dispensing team, pharmacy technicians can directly impact medication safety. Many patient and medication safety hazards exist in a pharmacy setting, and workflow strategies and technological innovations have been developed and implemented to reduce the risk of medication errors. Still, medication errors are a significant source of preventable harm and, as their professional role expands, pharmacy technicians will be well-poised to improve medication safety.

INCIDENCE AND SIGNIFICANCE OF MEDICATION ERRORS

A medication error is defined by the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) as “any preventable event that may cause or lead to inappropriate medication use or patient harm.” Additionally, NCC MERP states that medication errors can occur “while the medication is in the control of the healthcare professional, patient, or consumer.”¹ This definition has been accepted by other agencies, including the Centers for Medicare and Medicaid Services and the Joint Commission.² Essentially, a medication error is a failure in any step of the medication-use process, including medication formulation and manufacturing, prescribing, administering, or monitoring, that can potentially harm a patient.³ Medication errors are a type of adverse drug event (ADE); ADEs include adverse drug reactions and medication errors.^4,5 Medication errors can be viewed as process errors, while adverse reactions are negative clinical outcomes. All adverse drug reactions cause patient harm, but not all adverse drug reactions are preventable. Conversely, all medication errors are preventable, but not all medication errors cause patient harm.²

Medication errors are one of the leading causes of patient harm in healthcare today. By definition, they are preventable, but they occur and recur at an alarming rate. Major causes of medication errors involve communication errors, including oral and written communication; name confusion, such as look-alike and sound-alike drug names; labeling errors; human factor errors, such as knowledge deficits and dose miscalculations; and errors related to the packaging or design of the drug product. According to most reports, medication errors occur most often during prescribing, dispensing, and administration of medications.⁵ The prescribing stage of medication use is the most susceptible to errors,^6,7 and illegible handwriting and misinterpretation of orders result in significant errors during the communication and transcribing processes.⁵ 

The quintessential report of medication safety was published by the Institute of Medicine (IOM). In its report, To Err is Human, IOM revealed that 1.5 million ADEs occur each year in the United States (U.S.), and medication errors cause at least 7000 deaths annually.⁸ Also, medication errors raise healthcare costs^2,7 and erode the confidence that patients have in the healthcare system.² It is noteworthy to consider that the original IOM report was based on data obtained from a review of medical records in 1984.⁹ The healthcare system has expanded dramatically in the last 3 decades, and new estimates suggest the rate and impact of errors may be more than 2 times as high as the original figures.^9-11

It is difficult to assess the true frequency of medication errors, in part because of the inconsistent definitions and methods that are used for detecting errors.^3,12 In fact, most errors likely go unnoticed or undetected.¹² One study reported error rates between less than 1% and greater than 90%, depending on the definitions and part of the healthcare system studied.⁶

Most information on medication errors is collected from hospital settings and estimates of medication errors from other settings are difficult to calculate.¹³ A 2003 report revealed that 1.7% of prescriptions dispensed from community pharmacies contained errors (the error rate ranged from 0% to 3%); only 0.1% of those were deemed clinically relevant, but that still equated to an annual incidence of 50,000 errors. Interestingly, most of the errors were related to incorrect label information and instructions for use.¹² Unfortunately, despite decades of medication safety awareness, little quantitative change has occurred related to the incidence of medication errors. A meta-analysis published in 2018 reported that the dispensing error rate in community pharmacies was 1.5% among nearly 1.5 million prescriptions (rates ranged from 0.0003% to 55%, varying markedly with study methodology). Very few studies describe the rates of dispensing errors, but the authors of the meta-analysis concluded that error rates are likely higher than predicted.¹⁴ The average error rates in hospital settings have been reported to be similar to the rates reported in community settings (range, 0.04% to 2.9%).^12,15

Poison control centers manage phone calls concerning medication errors and adverse drug reactions from patients, caregivers, and healthcare professionals. Many calls are received from outside of the healthcare setting, often from patients or caregivers who are at home. Data indicate that the medication error rate among callers to U.S. poison control centers is 8.46 per 10,000.¹³ Among children, errors occur at an alarming rate of 1 error every 8 minutes.¹⁶ Analgesics are the most frequently cited drug class associated with human exposures necessitating a call to poison control centers, followed by sedatives/hypnotics/antipsychotics and antidepressants.¹⁷ Medication errors outside of a healthcare setting continue to be a preventable source of injury.¹³

Notably, serious medication errors are uncommon.¹² According to a study of an anonymous medication error reporting system, MedMARx, 98% of errors result in no harm to patients.² However, when errors do reach the patient, serious and fatal outcomes can occur.² Medication errors occur more frequently, and tend to be more serious, in very young and very old patients compared with other patient groups.^3,5,6,16

TYPES OF MEDICATION ERRORS

Many definitions of medication errors have been published, and various systems are used to categorize errors. Errors can occur through ignorance or inadvertence; they can occur during calculation, judgment, speech, writing, or action; they can be made by physicians, nurses, pharmacists, technicians, or other healthcare professionals¹²; and they can also be made by patients themselves. It is estimated that one-half of individuals who use medications do so incorrectly or inappropriately.⁴

Medication errors can occur during any stage of the medication-use process. They may occur in isolation, but most errors are related to other faults or system failures.¹⁸ Two broad systems can be used to categorize errors. One system describes where or when errors occur in the medication-use process while the other explains the type and/or reason for the error. The categories are not mutually exclusive. Examples of errors in the medication-use process are outlined in Table 1^4,12,19; these examples include prescribing errors, administration errors, and compliance errors among others. Potential errors, or near-misses, are errors made in the medication-use process that are identified and corrected prior to patient administration.¹²

The types of errors that occur during the medication-use process can be classified as human failures, technical failures, or organizational failures. A human failure error occurs at the individual level and is related to performance, which may include a lack of education or training or a failure to follow organizational policies and procedures. A technical failure error results from environmental factors or equipment malfunctions. Examples of technical failures include poor lighting, noise, low staffing levels, or distractions in the workspace. An organizational failure error occurs when rules or policies direct the inappropriate selection, preparation, or administration of a medication.¹⁹ However, multiple factors contribute to medication errors in pharmacy settings.²⁰

A survey of community pharmacy technicians revealed that interruptions and inadequate staffing were the most frequent causes of medication errors.²¹ Insufficient pharmacist coverage coupled with increasing pharmacist responsibilities also contribute to an increased workload and increased errors.²² Other common sources of medication errors that occur in community pharmacies include handwritten prescriptions, similar packaging or naming conventions, and lack of control in the process of preparing and labeling prescriptions.²³

DETECTION, INTERVENTION, PREVENTION, AND REPORTING OF MEDICATION ERRORS

The most practical methods of error detection include chart review, computerized monitoring, searching administration databases and claims data, direct observation, incident reporting, and patient monitoring. Regardless of how errors are detected, communication is key—not just among healthcare professionals but with patients and caregivers, as well.³

Focusing on why and how medication errors happen allows for the development of techniques and systems that function to identify and prevent future errors. The U.S. Food and Drug Administration (FDA) operates MedWatch, an ADE reporting system for healthcare providers, patients, and consumers. The MedWatch program is also used to monitor for potential medication errors. The Institute for Safe Medication Practices (ISMP) is another organization that collects and analyzes reports of medication errors and provides recommendations on how to prevent errors. Notably, ISMP is an FDA MedWatch partner and reviews MedWatch reports that contain information about medication errors. As a result of the error reports, ISMP and the FDA have launched programs to educate healthcare providers on strategies to mitigate common medication errors. Overall, ISMP has identified 10 key elements that have a significant impact on safe medication use:

• Patient information
• Drug information
• Medication-related communication
• Drug labeling, packaging, and naming system
• Drug standardization, storage, and distribution
• Drug device acquisition, use, and monitoring
• Environmental factors
• Staff competency and education
• Patient education
• Quality-improvement processes and risk management

On the basis of these elements, ISMP promotes the availability of up-to-date information for prescribers; encourages collaboration among all healthcare team members and the patient; advises restricting access to drugs commonly reported in medication errors; advocates for systems that identify, report, and analyze medication errors; and offers recommendations for reducing the risk of medication errors.²⁴

In an effort to improve communication during the medication-use process, ISMP has developed a list of often-confused drug names. The list pairs drug names that look and/or sound alike; it was developed from medication errors that were reported to its Medication Errors Reporting Program (MERP). Importantly, special attention should be paid to a prescription whenever one of these drugs is involved. Some manufacturers and facilities use the practice of tall-man lettering to distinguish between similar drug names. (Tall-man lettering is the capitalization of portions of drug names that look and/or sound like other drug names.)²⁵ The entire list of drug names that has led to confusion among healthcare professionals is available on the ISMP website (https://www.ismp.org/recommendations/confused-drug-names-list), but some examples of confusing drug pairs (using tall-man lettering) are listed below²⁶:

• acetaZOLAMIDE/acetoHEXAMIDE
• Aciphex/Accupril
• Actos/Actonel
• aMILoride/amLODIPine
• AVINza/INVanz
• cycloSPORINE/cycloSERINE
• FLUoxetine/PARoxetine
• hydrALAZINE/hydroxyzine
• Neulasta/Lunesta
• Tiazac/Ziac
• ZyrTEC/ZyPREXA

Similar to the above-mentioned collection of drug names is ISMP’s list of high-alert medications. These drugs can cause significant patient harm and, therefore, require additional attention and vigilance in all steps of the medication-use process. The high-alert list includes drug classes, as well as specific medications, that are sources of noteworthy errors. Medications that appear on the high-alert list include (but are not limited to) carbamazepine, metformin, warfarin, all antiretroviral agents, all chemotherapeutic agents, insulin, opioids, pediatric medications that require measurement, and medications categorized as pregnancy category X. The entire list is available on the ISMP website.²⁷ Additionally, ISMP developed a list of error-prone abbreviations, symbols, and dose designations, which have been compiled from errors reported to MERP. The Joint Commission mandates that many of these abbreviations, symbols, and designations never be used when communicating medication information. The entire list is available on the ISMP website (https://www.ismp.org/recommendations/error-prone-abbreviations-list) , but examples include²⁸:

• the abbreviation “µg” for micrograms
• AD, AS, and AU and OD, OS, and OU for right ear, left ear, and both ears and right eye, left eye, and both eyes, respectively
• the abbreviation “cc” for cubic centimeters
• the abbreviation “q.d.” for daily
• the abbreviations “SSI” and “SSRI” for sliding scale insulin and sliding scale regular insulin, respectively

Further, drug names should not be abbreviated or written in shorthand. Trailing zeros should never be used after a decimal point, and a zero should always precede a decimal point when the dose is less than a whole unit (e.g., 0.9). ISMP’s main point of emphasis is clarity in communication—be clear, concise, and legible in all medical communications. When in doubt, write it out.²⁸

ISMP has several community pharmacy-focused systems and interventions to assist in mitigating risks associated with high-risk medications. ISMP also delivers urgent advisories about serious errors or immediate needs. Information in ISMP’s newsletter is obtained from practitioners and consumers who submit error reports to MERP or MedWatch. Additionally, ISMP has published a list of prescription container labeling practices that can be part of a strategy to increase patient understanding in order to improve medication safety. ISMP also offers literature that can be distributed to patients and consumers, which summarizes the importance of medication safety and outlines pharmacy’s role in the process of dispensing high-alert medications.²⁹

Information technology interventions

ISMP is not the only organization to support medication safety changes in healthcare. Clinicians, healthcare agencies, professional societies, and regulatory bodies have endorsed changes centered on the reduction of medication errors. Some recommendations include education and training on types of medication errors as wells as the use of information technology (IT) systems.³⁰ IT interventions include computerized order entry, automated dispensing cabinets, barcoded medication administration, and electronic medication reconciliation.^11,31 Barcode technology used in conjunction with electronic medication administration records has already improved the accuracy of medication administration processes and reduced errors in multiple hospital settings.³² For example, in a hospital pharmacy that implemented barcode-controlled dispensing of medications, the dispensing error rate decreased by 31%, which equated to a potential adverse event rate reduction of 63%.¹¹

Computerized order entry systems have reduced medication errors in several practice settings. These systems can identify patients who may be at high risk for a medication error or ADE, provide clinical decision support for prescribers, and assist with calculations.³³ Computerized physician order entry is viewed as a major intervention to reduce medication errors. Specifically, many prescribing errors, including wrong doses, wrong or omitted information, and inappropriate abbreviations, are lessened with clinical decision support tools that are part of the software programs.¹⁸

Electronic prescribing (e-prescribing) allows prescriptions to be transmitted directly from a provider’s office to a pharmacy. The goals of e-prescribing include decreased time between point of care and point of service, reduced medication errors, and improved care.^34,35 E-prescribing systems are safer, more formulary compliant, and more efficient than traditional paper prescriptions.³⁶ Nearly all community pharmacies have e-prescribing capabilities, and in a single year, a total of 1.2 billion electronic prescriptions (e-prescriptions) were transmitted to community pharmacies.^37,38

While computerized order entry and e-prescribing systems contribute to reduced medication errors, they are expensive to implement and they generate their own unique types of errors.^7,39 These systems reduce the risk of errors associated with illegible handwriting, but new types of errors are introduced by automated and computerized systems, including auto-population of order-entry fields, incorrect choices of medications, and incomplete or inaccurate electronic patient information.^3,7,34,35 One study reported that 1 in 10 e-prescriptions contained a medication error; one-third of these were potentially harmful.^35,40 Additionally, e-prescribing systems pose an increased cognitive burden on pharmacy staff for several reasons: (1) the need for multiple computer screens to enter prescriptions, (2) the need to establish new codes and abbreviations for products, (3) the need to mentally calculate doses and product sizes for products that are not easily measured, and (4) the need to communicate differently with prescribers and patients.⁴¹

One survey revealed that pharmacy staff members who were involved in processing e-prescriptions communicated with prescribers’ offices less by phone than those who were involved in processing traditional prescriptions.⁴¹ While this initially appears to be a benefit of e-prescribing, pharmacy staff members indicated that less frequent conversations with prescribers prevented them from being fully informed about patients’ overall care and well-being; instead, conversations tended to be more focused on fixing technical aspects of the prescriptions. When a patient hands a paper prescription across the pharmacy counter, the pharmacist and technician can immediately begin to create questions or a plan of action that is patient-focused. With an e-prescription, the patient simply arrives at the pharmacy after the prescription has been processed and prepared. Interestingly, patients who took part in the survey felt less connected to their pharmacy, and they often did not know how many medications had been prescribed or the indications for use.⁴¹

Pharmacy software programs often display alerts for safety reviews, but these alerts are frequently bypassed at the point of order entry before proper consideration is given to the alert. Some alerts are false-positives or not clinically relevant. Unfortunately, this has led to a climate in which alerts are ignored because of “alert fatigue,” which is the inclination to ignore alerts since many are clinically insignificant. One study reviewed more than 2 million medication orders and reported an alert override rate of more than 52%. More than half of the overrides were appropriate, but rates of appropriateness depended on alert type, including formulary substitutions, age-based recommendations, adjustments based on renal function, and patient allergies.⁴² Another study estimated the cost of ADEs resulting from alert overrides and reported that 5.5 million medication alerts were overridden, leading to 196,600 ADEs. The projected cost for treating these ADEs was between $871 million and $1.8 billion. Additionally, clinicians spent an estimated 175,000 hours responding to 78.8 million alerts, yielding an opportunity cost of $16.9 million.⁴³ E-prescribing and clinical alert systems have offered great benefit to the U.S. healthcare system, but pharmacists, technicians, and other stakeholders must agree on alert management practices to improve pharmacy software programs.^20,44

Medication reconciliation

Medication reconciliation is paramount for patient safety. It involves obtaining and comparing hospital medication orders with a patient’s home medications. According to one estimate, inadequate reconciliation accounts for nearly half of medication errors in hospitals. Medication errors can be reduced if medications are properly reconciled during transitions of care.² Interventions that incorporate pharmacy-based reconciliation programs have shown to be more effective and accurate than multidisciplinary reconciliation programs. Several pharmacy technician-managed programs in which a pharmacy technician interviews newly admitted patients and obtains medication lists and histories from multiple sources (e.g., community pharmacies, physician offices, and nursing facilities) have been able to effectively and accurately obtain, document, and communicate patient-specific medication reconciliation data. For example, the implementation of a program in a Florida hospital using pharmacy technicians in the emergency department to conduct medication reconciliation increased accuracy rates of medication histories from 57% to 88%.⁴⁵ A similar program conducted in 2015 found that the risk of errors in medication histories was significantly reduced by the involvement of well-trained pharmacy technicians when compared to non-pharmacy staff.⁴⁶ Medication reconciliation programs improve medication safety and transitions of care and likely have a role in other areas of patient care.^47-50

Some states, under specific protocols, allow “tech-check-tech” programs, in which technicians validate the order-filling accuracy of another technician. (Some federal pharmacy technicians are already allowed to practice under this model.) These programs offer medication-checking accuracy equivalent to that of a pharmacist. Improvements in technology and automation may lead to an expansion of tech-check-tech programs in various pharmacy practice settings.^51-53

Error reporting systems

The Joint Commission released the Sentinel Event Policy in 1996 to promote reporting of medication errors. A sentinel event is an unanticipated event in healthcare that results in death or serious physical or psychological injury to a patient (or has the potential to do so). When an organization reports a sentinel event, it is expected to analyze the cause of the event, correct the cause, monitor the changes that were developed because of the event, and determine whether the risk was eliminated. Healthcare organizations are required to have medication error-reporting systems in place in order to receive accreditation from the Joint Commission.^54,55

Medication error reporting should be encouraged since these reports identify areas in which errors are most likely to occur. Any medication error-reporting system should be readily accessible, and reporting should be followed up with feedback. However, the fear of disciplinary action prevents individuals from reporting errors, which also contributes to the difficulty in detecting and quantifying errors.¹² ISMP, along with other groups, advocates for a nonpunitive culture of safety within the healthcare system.⁵⁶ This philosophy incorporates a “just culture,” which is crucial to successful monitoring and reporting of medication errors. This attitude of organizational accountability focuses on system failures that led to an error, rather than the person, or persons, involved. Further, this concept avoids punishment for the error and, instead, uses the error as an opportunity to learn from and improve the system. Negligent or reckless behaviors are still punishable, and as such, a “just culture” still requires personal accountability. Employees are encouraged to report and document errors; more than that, however, they are encouraged to understand and mitigate the risks associated with medication errors. Determining why an error occurred and preventing future errors should take precedence over assigning blame to specific healthcare workers.²

Several mechanisms exist for reporting medication errors. All of these medication error-reporting systems tabulate and stratify errors with the aim of educating stakeholders about common sources of error. In some cases, data reported to these systems led to manufacturer changes in drug product naming or packaging and labeling. ISMP established MERP as a means for reporting medication errors by healthcare professionals, patients, and consumers. Similarly, the FDA’s MedWatch system is a voluntary surveillance program for adverse events related to marketed drugs and devices. The system receives more than half a million reports every year from healthcare professionals, patients, and consumers, and it has been credited with increasing the awareness of drug-related risks, especially for newly marketed products. Errors reported to MedWatch involve not only prescription and over-the-counter drug products, but also vitamins, nutritional supplements, infant formulas, and cosmetics.⁵⁷ In addition, MedMARx is a reporting system supported by the United States Pharmacopeia (USP). It is an Internet-based system that enables hospitals and healthcare providers to anonymously document and track adverse events for a specific institution.⁵⁸ Importantly, there are no mechanisms for verifying the accuracy or completeness of the adverse events reported to these systems.⁵⁷ A more uniform and standardized system would strengthen the quality of data reported to medication safety programs.⁵⁹

THE ROLE OF THE TECHNICIAN IN MEDICATION SAFETY

The following roles of pharmacy technicians are critical to pharmacy practice: receiving and filling prescriptions, packaging doses, ordering stock, controlling inventory, compounding products, managing automated dispensing systems, and distributing medications to patients. To prevent errors and minimize risks associated with medication use, technicians should follow policies, procedures, and practices outlined by their respective practice sites and engage the pharmacist whenever a concern arises.⁶⁰ Further, education is critical among error prevention methods.³ Specifically, technicians can maintain their own professional competency and encourage colleagues to do the same. Technicians can also help devise system-based solutions to improve quality of care and patient safety.^61,62

The responsibilities of pharmacy technicians are limited and must be accomplished under the direct supervision of a pharmacist; however, the roles and responsibilities of technicians will likely expand as pharmacists shift their time and efforts toward direct patient care.⁶⁰ For example, the American Society of Health-System Pharmacists (ASHP) supports an expanded role of technicians in pharmacy informatics. Such roles include automation and technology systems management, project management, training and education, policy and governance, customer service, and reporting.⁶³ The ASHP also recommends that pharmacy technicians should be trained to identify the roles and limitations of MedWatch and MERP, in addition to understanding how multiple factors can impact medication errors. Finally, ASHP suggests that technicians should participate in formulating a strategy for the prevention or recurrence of clinically significant medication errors.⁶³ In addition, the Pharmacy Technician Certification Board instituted changes to its certification program in 2014. Specifically, technicians must complete 1 hour of continuing education that is focused on medication safety during the recertification process.⁶⁴ These initiatives underscore the important role of the pharmacy technician in the area of medication safety.

Many strategies for error detection and prevention apply to multiple practice settings. In a community pharmacy, medication errors at prescription drop-off are usually related to missing or incorrect patient information. Such information might include incorrectly identifying the patient profile or not recording drug allergies or health conditions. Lack of patient information that concerns lab results, disease states, or basic patient information, which may originate at the pharmacy or the hospital or prescriber’s office, is responsible for an estimated 14% of prescribing errors.⁶⁰ Pharmacy technicians should verify multiple patient identifiers, including name, address, or birth date, to ensure that the correct profile has been selected in the order entry system. In addition, technicians should inquire about allergy information and other health conditions when interacting with patients. This information must always be added—and updated—to every patient’s profile as it is a critical element on which pharmacists base their therapeutic decisions.⁵⁵

Errors can also occur during data entry. These types or errors are often associated with missing or incorrect drug information. Also, illegible handwriting and the use of unapproved or incorrect abbreviations lead to misinterpretation of drug information, resulting in incorrect data entry and patient profile maintenance. Despite being educated to avoid the use unapproved abbreviations, prescribers continue to use them. Technicians must be able to recognize improper abbreviations and call them to the attention of the pharmacist for verification. Often, drug names are cumbersome and look and sound like other drug names. Therefore, pharmacy technicians must be aware of the distinctions related to drug names in order to identify potential errors. Also, computer systems often alert users to high-risk medications, so it is essential that pharmacy staff members who are entering medication information read and address the alerts.^44,65,66

During the prescription-filling process, it is easy to select the wrong stock bottle from a pharmacy shelf since many medications have names and packages that look and sound alike. Many pharmacies have systems in place, such as barcode scanning or National Drug Code verification, to decrease the likelihood of choosing the wrong drug product. Errors can also occur at the point of sale if a prescription is dispensed to a patient for whom it was not intended. Thus, it is essential that pharmacy technicians verify the name and at least 1 other patient identifier before completing the purchase.⁵⁵

Compliance and social issues can also cause medication errors in the community setting. They are not entirely preventable by a healthcare provider or pharmacy staff, but steps can be taken to lessen these types of errors. For example, patients sometimes incorrectly administer their medications, both prescription and nonprescription products, resulting in ineffective treatment or adverse effects. Patients are nonadherent with medications for reasons related to cost, misinterpretation of dosing instructions, or they simply choose to not fill their prescription at all. Further, some patients stop taking a drug, or start taking a new one, without seeking the advice of a physician or pharmacist. All of these situations can lead to inappropriate medication-therapy management, ranging from underutilization of therapy to a toxic overdose. Technicians can help mitigate individual causes of medication errors by thoroughly reviewing a patient’s medication history to establish adherence. For example, patients who do not refill their prescriptions on time may be nonadherent, while patients who attempt to obtain refills too soon may be using their medication inappropriately. Once brought to the pharmacist’s attention, these issues can be addressed through patient counseling and education.⁵⁵ 

Patient case

You are a pharmacy technician at a community pharmacy. JP, a 39-year-old female, comes to your pharmacy and drops off a prescription for amoxicillin/clavulanic acid 875/125 mg, which is to be taken by mouth twice daily. She asks how long it will take to fill the prescription and then adds, “I hope this doesn’t give me a rash like the last time I had an antibiotic.” You look in her record and see that the allergy field is blank, and you do not see any previous antibiotics that have been filled by your pharmacy.

What should you do next?
A. Tell her to get this prescription filled at the other pharmacy, since you do not have her complete records 
B. Ask the pharmacist to counsel her immediately
C. Ask JP to clarify her allergies and medical history
D. Call JP’s physician and ask him to switch the medication to a different antibiotic

The correct answer is C. Technicians should ask patients for allergy information and health conditions and update new information in the system whenever a new prescription is dropped off. This information is critical for the pharmacist to determine if a drug is safe and appropriate for the patient.

You ask JP to recall the name of the drug and to explain what happened. She informs you that she was on vacation and got a sinus infection last year. She visited an urgent care facility and got her prescription filled at a community pharmacy in another state. She does not remember the name of the medication; however, after she took it, she developed a rash all over her body. She denies telling her physician about the reaction.

What is a potential source of error in this scenario?
A. JP has used more than one pharmacy to fill her prescriptions
B. JP does not know the name of her medications
C. JP’s pharmacy profile is not complete
D. All of the above

The correct answer is D. Medication errors are often multifactorial and involve both individual sources of error and system failures. In this case, there is a lack of updated and complete information as well as poor coordination of care among healthcare providers and pharmacies. Additionally, JP should keep a list of current medications and allergies and notify her physicians and pharmacy when changes or problems occur.

What advice should you offer JP?
A. Tell her to take the antibiotic with food in case it makes her nauseated
B. Enter allergies for all classes of antibiotics in JP’s patient profile, since she does not remember which specific drug she took previously 
C. Call the physician to ask for a new antibiotic
D. Encourage her to maintain records of her medical history and have the pharmacist speak to her about the safe and appropriate use of drug therapy

The correct answer is D. Pharmacy technicians cannot legally counsel patients, and until the pharmacist assesses the details of JP’s reaction, the prescription should not be filled. Obtain as much information as you can from the patient and then alert the pharmacist about the need for counseling and verification.

Although technicians cannot legally counsel patients, technicians can encourage patients to educate themselves about their health and medications. Patients should always know some basic information about their medications such as brand and generic names; what the medication looks like and why they are taking it; how much medication to take and how often to take it; what to do if they miss a dose; common side effects or precautions; and how to properly store the medication. Pharmacy technicians should always encourage patients to ask questions about their prescriptions.⁵⁵ The list below summarizes strategies that pharmacy technicians can use to increase the detection, identification, and prevention of medication errors^{12,25,41,55,67}:

• Carefully read the label each time a medication is obtained from the stock shelves or cabinets. Do not merely rely on visual recognition or location to verify a drug product
• Legibly print all drug names and doses to prevent confusion
• Implement storage strategies such as color-differentiation or boldface labeling for commonly confused medications
• Implement bar-coding for product verification
• Focus on the task at hand and work to minimize distractions and the desire to multitask
• Always double-check your work
• Always use 2 patient identifiers during order entry and at point of sale
• Do not make any assumptions: ask questions and obtain help when you are unsure of anything
• Be observant of errors and potential barriers to patient safety; report potential hazards to management
• Communicate openly with other staff members, supervisors, and patients
• Encourage patients to be engaged in their own healthcare and to ask questions of the pharmacist whenever drug information is unclear
• Listen for feedback and make changes to your work practices to ensure a safe environment

THE FUTURE OF MEDICATION SAFETY

Everyone makes errors. Healthcare professionals are more likely to make errors when they are inexperienced, inattentive, rushed, distracted, or tired.³ Pharmacy technicians cannot rely on their own vigilance to catch errors when a high cognitive load is required in a busy work environment. In fact, humans are only capable of using a small amount of working memory at one time, and multi-tasking is difficult when each task requires focus and attention.³⁸

Medications errors originate from many sources and can be avoided by taking various steps to minimize risks. System changes, such as education, standardization, and communication, are keys to decreasing the occurrence of medication errors in pharmacy practice.¹² The only way to truly prevent errors is to have every person in a pharmacy actively participate in safety procedures and look for ways to help minimize errors.⁶⁸

Pharmacy technicians are well-placed to detect and prevent medication errors. They have a unique perspective in the medication-use process and they can identify actual and potential sources of error before they reach the patient. Ultimately, pharmacy technicians must work with other members of the healthcare team and promote a safe environment for optimal patient care.⁶⁸

REFERENCES

1. National Coordinating Council for Preventing Medication Error Reporting and Prevention website. About medication errors. http://www.nccmerp.org/about-medication-errors. Accessed December 4, 2018.
2. Johnson SE. Principles and practices of medication safety. In: DiPiro JT, Talbert RL, Yee GC, et al, eds. Pharmacotherapy: A Pathophysiologic Approach. 9th ed. New York, NY: McGraw-Hill Education; 2014.
3. Aronson JK. Medication errors: EMERGing solutions. Br J Clin Pharmacol. 2009;67(6):589-91.
4. Tawfik KA, Jabeen A. Pharmaceuticals safety practices-a comparative pilot study. Int J Health Sci (Qassim). 2013;7(3):317-24.
5. Anathhanam S, Powis RA, Cracknell AL, Robson J. Impact of prescribed medications on patient safety in older people. Ther Adv Drug Saf. 2012;3(4):165-74.
6. Olaniyan JO, Ghaleb M, Dhillon S, Robinson P. Safety of medication use in primary care. Int J Pharm Pract. 2015;23(1):3-20.
7. Odukoya OK, Stone JA, Chui MA. E-prescribing errors in community pharmacies: exploring consequences and contributing factors. Int J Med Inform. 2014;83(6):427-37.
8. Kohn LT, Corrigan JM, Donaldson MS. To Err is Human: Building a Safer Health System. Washington, D.C.: Institute of Medicine; 2000.
9. James JT. A new, evidence-based estimate of patient harms associated with hospital care. J Patient Saf. 2013;9(3):122-8.
10. Aspden P, Institute of Medicine Committee on Identifying and Preventing Medication Errors. Preventing Medication Errors. Washington, D.C.: Institute of Medicine; 2006.
11. Agrawal A. Medication errors: prevention using information technology systems. Br J Clin Pharmacol. 2009;67(6):681-6.
12. Aronson JK. Medication errors: what they are, how they happen, and how to avoid them. QJM. 2009;102(8):513-21.
13. Brophy TJ, Spiller HA, Casavant MJ, et al. Medication errors reported to U.S. Poison Control Centers, 2000-2012. Clin Toxicol (Phila). 2014;52(8):880-8.
14. Campbell PJ, Patel M, Martin JR, et al. Systematic review and meta-analysis of community pharmacy error rates in the USA: 1993-2015. BMJ Open Qual. 2018;7(4):e000193.
15. Flynn EA, Barker KN, Carnahan BJ. National observational study of prescription dispensing accuracy and safety in 50 pharmacies. J Am Pharm Assoc (Wash). 2003;43(2):191-200.
16. Smith MD, Spiller HA, Casavant MJ, et al. Out-of-hospital medication errors among young children in the United States, 2002-2012. Pediatrics. 2014;134(5):867-76.
17. Gummin DD, Mowry JB, Spyker DA, et al. 2016 annual report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 34^th annual report. Clin Toxicol (Phila). 2017;55(10):1072-252.
18. Carayon P, Wetterneck TB, Cartmill R, et al. Characterising the complexity of medication safety using a human factors approach: an observational study in two intensive care units. BMJ Qual Saf. 2014;23(1):56-65.
19. Aronson JK. Medication errors: definitions and classification. Br J Clin Pharmacol. 2009;67(6):599-604.
20. Ojeleye O, Avery A, Gupta V, Boyd M. The evidence for the effectiveness of safety alerts in electronic patient medication record systems at the point of pharmacy order entry: a systematic review. BMC Med Inform Decis Mak. 2013;13:69.
21. Desselle SP. Certified pharmacy technicians' views on their medication preparation errors and educational needs. Am J Health Syst Pharm. 2005;62(19):1992-7.
22. Pervanas HC, Revell N, Alotaibi AF. Evaluation of medication errors in community pharmacy settings: a retrospective report. J Pharm Technol. 2016;32(2):71-4.
23. Knudsen P, Herborg H, Mortensen AR, et al. Preventing medication errors in community pharmacy: root-cause analysis of transcription errors. Qual Saf Health Care. 2007;16(4):285-90.
24. Institute for Safe Medication Practices website. Key elements of medication use. https://www.ismp.org/ten-key-elements. Accessed December 4, 2018.
25. Darker IT, Gerret D, Filik R, et al. The influence of 'Tall Man' lettering on errors of visual perception in the recognition of written drug names. Ergonomics. 2011;54(1):21-33.
26. Institute for Safe Medication Practices website. List of confused drug names. https://www.ismp.org/recommendations/confused-drug-names-list. Published February 16, 2015. Accessed December 4, 2018.
27. Institute for Safe Medication Practices website. High-alert medication in community/ambulatory settings. https://www.ismp.org/recommendations/high-alert-medications-community-ambulatory-list. Published November 20, 2017. Accessed December 4, 2018.
28. Institute for Safe Medication Practices website. List of error-prone abbreviations. https://www.ismp.org/recommendations/error-prone-abbreviations-list. Published October 2, 2017. Accessed December 4, 2018.
29. Institute for Safe Medication Practices website. Medication Safety Self Assessment for Community/Ambulatory Pharmacy. https://www.ismp.org/assessments/community-ambulatory-pharmacy . Published January 23, 2017. Accessed December 4, 2018.
30. Agrawal A, Aronson JK, Britten N, et al. Medication errors: problems and recommendations from a consensus meeting. Br J Clin Pharmacol. 2009;67(6):592-8.
31. Nguyen PA, Syed-Abdul S, Iqbal U, et al. A probabilistic model for reducing medication errors. PLoS One. 2013;8(12):e82401.
32. Seibert HH, Maddox RR, Flynn EA, Williams CK. Effect of barcode technology with electronic medication administration record on medication accuracy rates. Am J Health-Syst Pharm. 2014;71(3):209-18.
33. Lainer M, Mann E, Sonnichsen A. Information technology interventions to improve medication safety in primary care: a systematic review. Int J Qual Health Care. 2013;25(5):590-98.
34. Kannry J. Effect of e-prescribing systems on patient safety. Mt Sinai J Med. 2011;78(6):827-33.
35. Odukoya OK, Chui MA. E-prescribing: a focused review and new approach to addressing safety in pharmacies and primary care. Res Social Adm Pharm. 2013;9(6):996-1003.
36. Richman M, Joo J, Rohani P. Transitioning to e-prescribing: preformatted prescription forms improve safety, formulary compliance, prescribing satisfaction, and perceived efficiency. J Patient Saf. 2018;14(4):241-5.
37. Odukoya OK, Schleiden LJ, Chui MA. The hidden role of community pharmacy technicians in ensuring patient safety with the use of e-prescribing. Pharmacy (Basel). 2015;3(4):330-43.
38. Gabriel MH, Swain M. E-Prescribing Trends in the United States. ONC Data Brief, no.18. Washington, DC: Office of the National Coordinator for Health Information Technology; July 2014.
39. Abramson EL. Causes and consequences of e-prescribing errors in community pharmacies. Integr Pharm Pract. 2015;5:31-8.
40. Nanji KC, Rothschild JM, Salzberg C, et al. Errors associated with outpatient computerized prescribing systems. J Am Med Inform Assoc. 2011;18(6):767-73.
41. Odukoya OK, Chui MA. e-Prescribing: characterisation of patient safety hazards in community pharmacies using a sociotechnical systems approach. BMJ Qual Saf. 2013;22(10):816-25.
42. Nanji KC, Slight SP, Seger DL, et al. Overrides of medication-related clinical decision support alerts in outpatients. J Am Med Inform Assoc. 2014;21(3):487-91.
43. Slight SP, Seger DL, Franz C, et al. The national cost of adverse drug events resulting from inappropriate medication-related alert overrides in the United States. J Am Med Inform Assoc. 2018;25(9):1183-8.
44. Isaac T, Weissman JS, Davis RB, et al. Overrides of medication alerts in ambulatory care. Arch Intern Med. 2009;169(3):305-11.
45. Hart C, Price C, Graziose G, Grey J. A program using pharmacy technicians to collect medication histories in the emergency department. P. T. 2015;40(1):56-61.
46. Rubin EC, Pisupati R, Nerenberg SF. Utilization of pharmacy technicians to increase the accuracy of patient medication histories obtained in the emergency department. Hosp Pharm. 2016;51(5):396-404.
47. Sen S, Siemianowski L, Murphy M, McAllister SC. Implementation of a pharmacy technician-centered medication reconciliation program at an urban teaching medical center. Am J Health-Syst Pharm. 2014;71(1):51-6.
48. Smith SB, Mango MD. Pharmacy-based medication reconciliation program utilizing pharmacists and technicians: a process improvement initiative. Hosp Pharm. 2013;48(2):112-9.
49. Petrov K, Varadarajan R, Healy M, et al. Improving medication history at admission utilizing pharmacy students and technicians: a pharmacy-driven improvement initiative. P. T. 2018;43(11):676-84.
50. Irwin AN, Ham Y, Gerrity TM. Expanded roles for pharmacy technicians in the medication reconciliation process: a qualitative review. Hosp Pharm. 2017;52(1):44-53.
51. Adams AJ, Martin SJ, Stolpe SF. "Tech-check-tech": a review of the evidence on its safety and benefits. Am J Health-Syst Pharm. 2011;68(19):1824-33.
52. Fleagle Miller R, Cesarz J, Rough S. Evaluation of community pharmacy tech-check-tech as a strategy for practice advancement. J Am Pharm Assoc (2003). 2018;58(6):652-8.
53. Frost TP, Adams AJ. Pharmacist and technician perceptions of tech-check-tech in community pharmacy practice settings. J Pharm Pract. 2018;31(2):190-4.
54. Sentinel event policy and procedures. The Joint Commission website. http://www.jointcommission.org/Sentinel_Event_Policy_and_Procedures/. Published June 29, 2017. Accessed December 4, 2018.
55. Shah B, Gibson JL, Tex NL. The 21st Century Pharmacy Technician. Burlington, MA: Jones & Bartlett Learning, LLC; 2013.
56. About ISMP. Institute for Safe Medication Practices website. https://www.ismp.org/about. Accessed December 4, 2018.
57. Getz KA, Stergiopoulos S, Kaitin KI. Evaluating the completeness and accuracy of MedWatch data. Am J Ther. 2014;21(6):442-6. 
58. Enriksen K, Battles JB, Marks ES, et al. Advances in Patient Safety: From Research to Implementation (Volume 4: Programs, Tools, and Products). Rockville, MD: Agency for Healthcare Research and Quality; 2005. AHRQ publication 05-0021-4.
59. Knudsen P, Herborg H, Mortensen AR, et al. Preventing medication errors in community pharmacy: frequency and seriousness of medication errors. Qual Saf Health Care. 2007;16(4):291-6.
60. Jenkins A, Eckel SF. Analyzing methods for improved management of workflow in an outpatient pharmacy setting. Am J Health-Syst Pharm. 2012;69(11):966-71.
61. American Society of Health-System Pharmacists. ASHP/ACPE Accreditation Standards for Pharmacy technician Education and Training Programs. Bethesda, MD: American Society of Health-System Pharmacists; 2018. https://www.ashp.org/-/media/assets/professional-development/technician-program-accreditation/docs/ashp-acpe-pharmacy-technician-accreditation-standard-2018.ashx?la=en&hash=36EAA6511105A6C6BFEA4F30E193892F19E2C385. Accessed December 4, 2018.
62. Pharmacy Technician Certification Board website. Pharmacy technician certification examination (PTCE) content outline. https://www.ptcb.org/docs/default-source/about-ptcb/ptce-content-outline-effective-january-1-2020.pdf?. Published November 2018. Accessed December 4, 2018.
63. ASHP statement on the pharmacy technician's role in pharmacy informatics. Am J Health-Syst Pharm. 2014;71(3):247-50.
64. Pharmacy Technician Certification Board website. Continuing education. https://www.ptcb.org/renew/continuing-education. Accessed December 4, 2018.
65. Weingart SN, Simchowitz B, Padolsky H, et al. An empirical model to estimate the potential impact of medication safety alerts on patient safety, health care utilization, and cost in ambulatory care. Arch Intern Med. 2009;169(16):1465-73.
66. Weingart SN, Simchowitz B, Shiman L, et al. Clinicians' assessments of electronic medication safety alerts in ambulatory care. Arch Intern Med. 2009;169(17):1627-32.
67. Filik R, Purdy K, Gale A, Gerrett D. Labeling of medicines and patient safety: evaluating methods of reducing drug name confusion. Hum Factors. 2006;48(1):39-47.
68. Seidling HM, Kaltschmidt J, Ammenwerth E, Haefeli WE. Medication safety through e-health technology: can we close the gaps? Br J Clin Pharmacol. 2013;76(Suppl 1):i-iv.

Back to Top

« Return to Activity