Letter to the Editor
August 7, 2014
IN RESPONSE to PD’s article about
a Pharmacy Board of Australia
warning regarding dispensing errors
(PD 01 Aug), PDL has written this
response:
A recent communiqué from the
Pharmacy Board of Australia wrote
about the danger and implications
of not using scanners in the
dispensing process.
From cases reported to PDL,
it is estimated that 80-90% of
dispensing errors result from a
failure to scan and not adequately
checking dispensed prescriptions.
Therefore, PDL fully endorses the
comments made by The Board.
When a dispensing error is made,
problems can occur not only to the
recipient of the mistake but to the
dispensing pharmacist as well.
Some pharmacists involved in
errors, especially serious errors, can
be traumatised or become highly
stressed as a result of causing injury
to a consumer.
The simple act of scanning can
therefore protect the pharmacist as
well as the consumer.
A recent trend in dispensing
incidents has emerged where
dispensed medication is given out
to the wrong person.
This occurs when a consumer
name is called and the wrong
person comes forward to claim it.
Through lack of proper consumer
checking and often a failure to
adequately counsel, these errors
are becoming prevalent. By
asking ‘open questions’, this type
of mistake can be completely
eliminated.
Likewise, transposing the names
of family members is happening too
frequently, so Mr Jones may have a
prescription labelled as Mrs Jones.
Another cause for alarm in the
dispensing process involves the
provision of Dose Administration
Aids.
Increasingly, we are receiving
reports of errors in the filling and
the distribution of DAAs.
Incorrect filling of these aids often
involves packs filled by dispensary
assistants and the final checking of
a pharmacist failing to detect an
error.
The recent and well publicised
death of a patient due to incorrectly
packed methotrexate has been
well documented but other serious
errors have recently occurred.
Errors in warfarin dosing have led
to consumers having a stroke on
more than one occasion.
Mistakes in packing tranquilisers
and sedatives have also had
obvious deleterious results.
The lessons to be learnt from
the above are simple and should
not require intervention by the
Pharmacy Board to bring to the
attention of pharmacists.
Put plainly; always scan; counsel
appropriately; double and triple
check your work and analyse and
think clearly about what you are
doing!
We welcome any comments.
If you would like to weigh in on
this or other subjects, email us at
info@pharmacydaily.com.au.
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