USP Quality Review

No. 67, Issued June 1999

Recommendations for Avoiding Error-Prone Aspects of Dispensing Medications

Figure 3

Recommendations for Avoiding Error-Prone Aspects of Dispensing Medications
  1. The Council recommends that prescriptions/orders always be reviewed by a pharmacist prior to dispensing. Any orders that are incomplete, illegible, or of any other concern should be clarified using an established process for resolving questions.

  2. The Council recommends that patient profiles be current and contain adequate information that allows the pharmacist to assess the appropriateness of a prescription/order.

  3. The Council recommends design of the dispensing area to prevent errors. Design should address fatigue-reducing environmental conditions (e.g., lighting, air conditioning, noise level, ergonomic fixtures), minimize distractions (e.g., telephone and personnel interruptions, clutter, unrelated tasks), and provide sufficient resources for workload.

  4. The Council recommends that product inventory be arranged to help differentiate medications from one another. This may include the use of visual discriminators such as signs or markers. This is particularly important when confusion exists between or among strengths, similar looking labels, and similar sounding names.

  5. The Council recommends that a series of checks be established to assess the accuracy of the dispensing process prior to the medication being provided to the patient. Whenever possible, an independent check by a second individual should be used. Other methods of checking include the use of automation, computer systems, and patient profiles.

  6. The Council recommends that labels be read at least three times, for example, when selecting the product, when packaging the product, and when returning the product to the shelf.

  7. The Council recommends that pharmacists counsel patients. Counseling should be viewed as an opportunity to verify the accuracy of dispensing and the patient's understanding of proper medication use.

  8. The Council recommends that pharmacies collect data regarding actual and potential errors for the purpose of continuous quality improvement.

Approved by the National Coordinating Council for Medication Error Reporting and Prevention, March 19, 1999