Detection and prevention of ambulatory care pharmacy dispensing errors

There have been few studies of errors committed in ambulatory care pharmacies. Errors can be classified as incorrect strength, wrong product, wrong dosage form, wrong quantity, incorrect or omitted labeling (such as directions, patient's name, prescriber's name, auxiliary label, drug name, or strength), dispensing deteriorated drugs, and dispensing in non-childproof containers. Errors can be prevented by possessing and using knowledge, by proper performance and by having good systems in effect to prevent and/or uncover errors. Some contributing factors, which cause errors, are distraction and interruption, poor work habits, thoughtless robot-like performance, workloads past the safety threshold, poor working conditions, poorly written and incomplete prescriptions. A prime system to prevent errors from reaching the patient is the old tried and true system of having work checked by another person. The use of patient profiles can aid in reducing errors. The activity of patient counseling can reduce errors. Suggestions are made to reduce the number of errors made. A simple quality assurance program is presented. Case studies of medication errors are presented. The future use of bar-coding should be an extremely useful tool for preventing medication errors.