There are key steps that pharmacists and their teams can take to minimise the risk of errors happening and to safeguard their patients.

  • Dispensing2
    Keep dispensary surfaces clear of clutter.
  • Keep medicines for different patients clearly segregated.
  • Ensure staff who put away dispensary deliveries take extra care when putting the delivery to shelf to ensure products are placed in the correct location.
  • Review the dispensary layout.
  • Review staffing levels- do these match the peak dispensing pattern.
  • Review SOPs and ensure all pharmacy staff are familiar with them.
  • Physically separate products with similar names or packaging on dispensary shelves.
  • Ensure split packs are clearly marked, and when checking inspect the contents of each pack not only the outer box.
  • Ensure robust date checking processes are implemented.
  • Take regular mental breaks when checking prescription accuracy.
  • Minimise distractions, do not do more than one task at once or to work too quickly.
  • Prepare for busy dispensing periods such as bank holidays, try to plan ahead and be organised.
  • Take extra care with checking prescriptions that have been prepared by inexperienced or trainee staff.
  • Consider high risk items such as insulin and show the product to the patient before supplying (clear plastic bags for fridge lines can facilitate this process before putting into an opaque bag to protect confidentiality).
  • Take care when checking MDS/MCA to ensure there are no missing medicines, doses in incorrect time slots or changes in dose, strength or formulation that have been missed.
  • Review records of all errors and near misses and take action to prevent recurrence.
  • Highlight patient PMRs where unusual drugs or strengths are routinely prescribed.

Numark members who would like further assistance regarding action to take following an error or to prevent an error should contact Numark Information Services on 0800 783 5709 option 2* or via NumarkNet.