Pharmacy Connection, March/April 1995

Although pharmacists try very hard to avoid them, dispensing errors are a reality in pharmacy practice.

How a pharmacist handles a dispensing error often has a direct effect on how the patient reacts, and affect the likelihood of another error occurring at the same pharmacy.

To help pharmacists adhere to correct procedures when a dispensing error takes place, the College Complaints and Professional Practice Committees have developed two documents.

The first, a Suggested Protocol for the Handling of Dispensing Errors (page 28), illustrates what the Committee recommends a pharmacist should do if a dispensing error occurs. The underlying principles of this document were:
1. To deal with this situation promptly and completely.
2. To be honest with the patient, and keep him/her informed.
3. To determine the exact cause of the error, and take corrective action to prevent future errors.

The second document is an Incident Form (page 29), similar to those used in hospitals. This form, which is strictly for internal pharmacy use, can ensure that all the steps in the Protocol have been followed, and that there is proper follow-up with the patient or agent.

The professional Practice Committee recommends that each pharmacy establish a file for these reports as an internal quality assurance tool. It also suggests that pharmacists post the Protocol in the dispensary for handy reference.