IN A PROFESSION WHERE THE expectation is 100% accuracy, the reality is inconsistent with this goal. Different values are cited across the internet, but by and large 99.7% accuracy is considered a standard in the practice of pharmacy. Any pharmacist will tell you that while making three mistakes in 1,000 prescriptions filled is reasonable, they also fear the outcomes of those three mistakes. In a litigious society where everyone is a target, pharmacists are expected by the courts, patients, and employers to be perfect.
The reality is that pharmacy doesn’t stack up very well against general industry standards for accuracy, either. Six Sigma is the most common metric and statistical science for an acceptable error rate in the world of manufacturing, for example. It states that to not lose consumer confidence, one must have no more than 3.4 defects per million. Unfortunately, pharmacy is coming closer to 3,000 mistakes/defects per million, which is certainly less than ideal.
In light of this, how do we as a profession work toward reducing errors even further? We’ve all been schooled on the basic concepts, such as rereading the hard copy against the label with checkmarks, checking the NDC of the label against the bottle (commonly using the middle four digits), and using technology such as machines and pill counters to assist in getting the proper amounts ready for dispensing. Here are some concepts that go beyond the common suggestions and may help you reduce errors in your environment.
KNOW YOUR SOFTWARE
It sounds silly, but the first step in knowing what errors you are going to encounter is to understand the limitations of the software you are using. One example is short codes. We all use them when applicable, but is the short code going to give you erroneous data? Does “1QD” give you “capsules” when you need “tablets”? Does it give you totally wrong information when dealing with topical versus ophthalmic solutions? A number of software solutions allow you to set up 1T versus 1C for tablet versus capsule, but all this means is that staff members are more apt to give you a bad set of directions as they get in the habit of typing one short code over another. Understanding how the software crafts the SIG will help you watch out for wording that is incorrect.
Knowing the software is not limited to knowing the sig or short codes, but also involves how the drug itself is selected. More is better, but folks get lazy, and so instead of typing five characters to limit their field of options, they will only use three and try to select from the list. Getting into the habit of trying to spell the drug name out as much as possible will help keep the bad options off the grid. If available, an additional help may be found if the drug selection field allows for a search that includes strength as well as name. Inputting, “HYDRO 50MG” versus “HYDRO 500MG” is the difference between seeing options of HCTZ 50mg and HYDREA 500mg. While this isn’t identified as a common error, the list of HYDRO items is no doubt long, even in the smallest of pharmacies. The goal in drug selections is to narrow the criteria as much as possible, and thus narrow the possibility of an error.
Some recommendations the makers of every good piece of software should consider adding, if they don’t have it already, are:
❏ A “fuzzy logic” search. There are times when we are faced with a poorly written prescription and the first few letters are illegible. Being able to search by a portion of the word as well as the strength and dosage form enables the user to see valid options and make the mental connections of how a provider may have been writing the letters. Thus, searching Prozac 20mg capsules by “*zac 20 cap” (where * is a wild-card character meaning anything can be before the characters following it) may help you or your staff understand the first letter is a P and not an L, or in some other language. Pharmacists are excellent detectives, and good software should allow us to hone those skills more.
❏ An alternate name search by default. Searching for the HIV drug Biktarvy is great, if the prescriber writes that name. If he or she happens to write bictegravir/emtricitabine/tenofovir in some order, the tech probably has no chance of finding the drug, and the pharmacist is most likely pulling up reference material to determine what it is. With so many drugs coming to market so quickly, the ability to search by whatever the prescriber wrote and get back reasonable matching results is priceless from a time and labor standpoint. Searching available brand and generic fields, even if the generic has yet to be brought to market, is valuable to a good technician.
❏ Ability to add warnings within the software. Being able to add a caution flag or to stop or slow down a specific technician or all staff members on recurring mistakes can be helpful in preventing them. While you never want every drug tagged in this manner, as it becomes “white noise,” having a targeted approach toward using flags for error prevention can help with drug selection, package size confusion, days’ supply issues for insurance claims, and proper sig code selection, among other concepts. These types of warnings should always be more than a simple “OK” acknowledgement. Instead, they should be something that stops the user and is logged so that it is clear the warning was observed and overridden.
❏ The ability to “force” dispensings in a certain package increment. The staff should never have to remember how many grams are in a Ventolin, ProAir, or Qvar inhaler. The software should tell them and, in cases like these, the software should have the option to force and check those values. The concept of sending a partial package for anything other than an oral medication should be challenged by the software.
In certain circumstances and environments, it may be possible to request software changes to assist in your company’s error prevention efforts. While not everyone has that luxury, taking advantage of it can allow someone to craft concepts that go beyond standard alerts. One such example is a drug barrier string. The concept of this is to disallow selection of a given drug until enough characters have been typed to essentially “unlock” the drug. This concept is unique in that it helps prevent errors at the point of entry and forces users to pay attention and adhere to limitations placed upon them. This change to computer concepts moves the system from being a glorified typewriter to a quality tool that helps one proactively block and reduce error options. CT
Matthew Catanzaro, R.Ph., is director of correctional services at Diamond Pharmacy
in Indiana, Pa. He can be reached at firstname.lastname@example.org.