Beyond Dispensing: Three Tactics to Improve the Application of Clinical Knowledge in Community Pharmacy Practice

Two pharmacy professionals discuss a medication in the dispensary.


In the world of pharmacy, where patient well-being is paramount, clinical knowledge serves as the bedrock of safe and effective medication use. From prescribing to dispensing, every step of the medication journey relies heavily on the expertise of pharmacy professionals. In this blog post, we’ll explore the vital role of clinical knowledge and share some key recommendations for ensuring patient safety in pharmacy practice.

The Consequences of Clinical Knowledge Gaps:

One of the most concerning trends in pharmacy practice is incidents related to clinical knowledge gaps. These incidents often involve unfamiliarity with medications or inappropriate clinical decisions. Unfortunately, such errors can have serious consequences, including harm to patients. Let’s delve into two real-life Manitoba incidents to illustrate the gravity of these errors:

Incident Example One: A Case of Hydromorphone Confusion

A patient was prescribed hydromorphone 6 mg by mouth every two hours for pain, as needed. The prescriber intended the patient to receive immediate-release hydromorphone, reinforced by the frequency of every two hours.

Due to its availability in 6mg tablets, the sustained release formulation, Hydromorph Contin®, was accidentally inputted and filled. The patient experienced sedation and brought the medication to the prescriber who recognized the error.

This incident highlights the role of clinical verification in ensuring the right medication, dose, and treatment plan.

Incident Example Two: A Dosing Error in Pediatrics

In another incident, an infant was prescribed amoxicillin/clavulanate for acute otitis media at a dose that significantly exceeded the recommended high-dose regimen of 90 mg/kg/day. The appropriateness of the dose was not verified, and the medication was dispensed. Another pharmacist recognized the error a few days later while processing the balance of the prescription a few days later. Unfortunately, the infant had already suffered from severe diarrhea and was seen by a physician.

This incident underscores the importance of meticulous dosing verification, especially in pediatric cases.

3 Key Recommendations for Ensuring Safety:

One: Facilitate Access to Medication Information

To empower pharmacy professionals in making informed decisions, it’s essential to provide electronic access to comprehensive medication information resources, including Canadian product monographs and relevant practice guidelines.

Two: Formalize Standard Operating Procedures (SOPs)

Clearly articulated SOPs for complex processes are invaluable. They not only set expectations but also establish accountabilities for pharmacy staff. Regular communication of these SOPs ensures that everyone is on the same page.

Three: Continuous Learning

The field of pharmacy is ever evolving and it’s imperative to provide targeted medication safety learning opportunities to staff. Resources are readily available from ISMP Canada, Safety IQ Academy and blog, the Institute for Healthcare Improvement, Health Excellence Canada, AHRQ, the Health Quality Councils of British Columbia and Alberta, and other medication and patient safety organizations.


Clinical knowledge is a cornerstone of safe and effective medication use in pharmacy practice. By recognizing its importance and implementing these key recommendations for safety, pharmacy professionals can further elevate the quality of care they provide to patients, ultimately ensuring their well-being and health.

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