Pharmacists engage in a number of processes during the course of practicing their profession. The standards of practice for both designated managers and pharmacists require the assessment of these processes to ensure that they are designed to minimize adverse events.
Several dispensing errors related to the process of logging and subsequent dispensing of logged prescriptions have been brought to the attention of the Complaints Committee through formal complaints. For the purpose of this article, logging a prescription refers to putting it on hold upon request by a patient. Other terms referring to the same process may be used in individual pharmacies.
There appears to be a misconception that if a logged prescription hardcopy is checked for accuracy by a pharmacist at the time the prescription is logged, the Dispensing Pharmacist has to check the hardcopy only and does not have to refer to the original prescription when dispensing the medication to the patient. The process of checking a hardcopy only routinely occurs during the dispensing of a prescription refill. It is important for pharmacists to recognize that the process for dispensing a logged prescription is not identical to the process for dispensing a prescription refill. The illustration below describes the two processes and highlights the differences.
While a Dispensing Pharmacist is not expected to check a prescription hardcopy against the original prescription when dispensing a refill (unless a therapeutic intervention or discrepancy is identified), a Dispensing Pharmacist is expected to thoroughly check a hardcopy against the original logged prescription to ensure that the medication is dispensed as prescribed.
The difference in these dispensing processes arises from the simple fact that for a prescription refill, the original prescription and hardcopy were thoroughly and completely reviewed when the drug was initially dispensed. Conversely, the initial check that occurs when a prescription is logged, while considered best practice for ensuring correct information is recorded on the patient’s profile, is certainly not a complete check and does not negate the necessity to check the hardcopy against the original prescription when the medication is being dispensed. Thus, the process for dispensing a logged prescription is identical to the process for dispensing a new prescription.
The following complaint reviewed by the Complaints Committee will illustrate the limitations of checking only a hardcopy when dispensing a logged prescription.
Complaint
The Complainant’s mother (“the Patient”) was prescribed 4 tablets of WarfarinŽ 1mg to be taken once daily. The Patient noted that she received WarfarinŽ 4mg with directions to take 4 tablets once daily.
The Patient contacted the pharmacist and was informed that the physician must have prescribed the dose dispensed. This resulted in the Patient contacting the physician to verify the dose and the physician in turn, informing the pharmacist that a dispensing error had occurred.
Pharmacists’ Response
The Designated Manager of the pharmacy explained that the prescription had been transferred to them and had been incorrectly logged. She described the procedure for logging prescriptions as one where the prescription was processed, the hardcopy generated was affixed to the prescription which was then reviewed by a pharmacist before being filed with the rest of the prescriptions. The Dispensing Pharmacist advised the Committee that when dispensing a logged prescription, the hardcopy that is generated is not checked against the original prescription as it is expected that a pharmacist had already performed this check when the prescription was logged.
Decision and Reasons
The Committee expressed its concerns that logged prescriptions were filed together with prescriptions that had been dispensed and that these logged prescriptions were not being thoroughly checked before being dispensed. The Committee determined that logged prescriptions must be checked in the same manner as new prescriptions as in both instances, the medications are being dispensed for the first time.
Consequently, the Committee issued a strong reminder to the Designated Manager to ensure that systems were in place at the pharmacy that clearly defined who was responsible for checking a logged prescription and when this check should occur.
The Committee noted that although the dispensing error resulted from an incorrectly logged prescription, the Dispensing Pharmacist was responsible for the error for the following reasons:
- She failed to check the prescription completely and thoroughly before dispensing the medication.
- She failed to use her therapeutic knowledge to assess the consequences of 16mg of WarfarinŽ on the Patient.
- She failed to review the Patient’s medication profile which would have indicated that the Patient had never previously been prescribed such a high dose.
- She failed to confirm the dose with the physician.
- She failed to follow up appropriately when the Patient expressed her concerns about the dose.
Due to the above concerns, the Committee directed the Dispensing Pharmacist to attend at the College to receive an Oral Caution and also directed her to successfully complete remediation related to both anticoagulation therapy and medication errors.
Conclusion
While this article focuses only on the process for logging and the subsequent dispensing of logged prescriptions, it is prudent for pharmacists and designated managers to critically analyze all the processes in place at a pharmacy to identify any steps or gaps in the processes that create an inherent risk for an error to occur. Once this analysis is completed, appropriate modifications to the processes should be undertaken to ensure that systems are in place to prevent the occurrence of adverse events.
