Introduction
In community pharmacy practice, maintaining the highest standards of patient safety and medication accuracy is a shared responsibility that extends to every member of the pharmacy team. A recent ISMP Canada analysis on harm incidents that happened in Manitoba pharmacies outlined several key recommendations aimed at enhancing safety during prescription processing. These recommendations underscore the critical role that not only pharmacists but also pharmacy support staff and management play in ensuring quality improvement and patient safety.
In this article, we will summarize the report’s key recommendations and suggested implementation roles for the entire team. Each pharmacy team member has a role to play in patient safety and we don’t need to wait to implement these simple improvements across the prescription process, including:
- Clinical Check: Assess the appropriateness of the prescription for the patient.
- Order Entry: Input prescription information into the pharmacy dispensing software.
- Dispensing: Select, prepare, package, and label medication.
- Technical Check: Confirm the accuracy of the order entry and dispensing steps.
- Patient Counseling: Provide sufficient information to enable safe and effective use.
- Pick-Up/Delivery: Provide medication to the patient or their agent.
Now, let’s explore the key recommendations for each group involved in these steps.
Pharmacy Technicians and Support Staff
Because of their intimate knowledge of the technical aspects of preparing medications, pharmacy technicians and support staff are ideal candidates to lead quality improvement and patient safety initiatives. Pharmacy technicians and support staff can implement and maintain the following key improvements to the order entry, dispensing, and pick-up and delivery steps of prescription processing:
Order Entry
- Standardize prescription intake using a questionnaire or checklist to identify/confirm relevant clinical information. This should include allergies and weight (especially for pediatric patients).
- Create a new entry for all new prescriptions and limit the copy function to new prescriptions that are unchanged from the previous prescription in the patient’s profile.
- Verify the printed compliance pack label (or medication administration record [MAR]) with the most up-to-date prescription for each medication.
Dispensing
- Ensure easy access to the prescription (including patient-specific requests), the master formulation record, and any other relevant resources during compounding. Highlight patient-specific requests to draw necessary attention.
- Arrange the work environment to facilitate safe vaccine dose preparation and verification (e.g., with minimal distractions, proper lighting, and a clean, uncluttered work area).
- Fill one medication (i.e., select the product, count as needed, and label the package) before working on another medication, to minimize the risk of mix-ups.
- Restart the task following an interruption to facilitate a clear, continuous thought process.
- Develop a process to identify and communicate the potential for errors when new drug products with look-alike names, labels, or packages are added to stock.
- Consider separate storage and auxiliary labels to distinguish look-alike products.
Pick-up/ Delivery
- Request a minimum of two patient identifiers at prescription pickup. Preferred identifiers, in addition to the patient’s name, include the person’s address and date of birth.
- At pickup, open the bag containing the prescriptions to ensure that each prescription label bears the intended patient’s name. This is the last opportunity to verify the appropriateness of each medication and confirm patient understanding.
Pharmacists
As medication experts, community pharmacists have a pivotal role to play in the health and safety of their patients. While focusing on the clinical aspects of pharmacy care, pharmacists can take on the following key improvements to the clinical check, technical check, and patient counselling steps of prescription processing:
Clinical Checks
- Develop a template for standardized communication with the prescriber regarding dose changes, including clarification of the previous and current doses.
- Develop a systematic process to follow when a medication regimen is adjusted in the middle of the compliance pack cycle. This may include:
- Make the change in the compliance pack label as soon as the new prescription is received. Set an alert in the system to remind staff of the change when the compliance pack is refilled.
- Clearly communicate the dose change to the patient and caregiver using the repeat-back method. The change can also be highlighted on the compliance pack label to bring attention to it during administration.
- Review the original prescription during the verification process – whether for new, hold, or refill prescriptions – to help identify incorrect order entries.
- Develop a standardized method of communication between all members of the patient’s circle of care, and especially during transitions of care.
- Conduct a medication review with patients and/or their caregivers on a regular basis (the frequency of which is dependent on the health status of the patient) to create an up-to-date list of all prescription, non-prescription, and natural health products currently being used.
- Assess the patient’s medications for appropriateness, effectiveness, safety, and convenience. This includes understanding the indication for each medication. Contact the prescriber to clarify any concerns.
- Provide the patient and/or caregiver with the updated list and encourage them to share it with all health care providers within the circle of care, especially at transitions of care.
- Reconcile this list with the patient profile in the dispensing software to ensure that active prescriptions reflect current medication use.
Technical Checks
- Conduct an independent double check of the medications in a compliance pack against the compliance pack label and the medication stock bottles.
- Perform an independent calculation to confirm the prescribed dose and quantity of the active pharmaceutical ingredient (API). If working alone, a colleague at a different pharmacy can support the double check process.
Patient Counselling
- Identify and document discussion points (e.g., on the prescription hardcopy) during the verification process. Attach the documentation to the filled prescription as an alert for the pharmacist to engage in patient dialogue before the prescription is released.
- This can include highlighting key information (e.g., half or quarter of a tablet) directly on the vial label or compliance pack label.
- Develop a standardized checklist of counselling points to discuss with the patient, both before (e.g., vaccine indication, expected side effects) and after (e.g., monitoring and follow-up) the vaccination.
- Using open-ended questions, ask the patient to state the expected medication and dose (e.g., “What is the name of your medication?” “What dose are you on?”).
- In the case of opioid agonist therapy, repeat the medication name and dose back to the patient for confirmation before providing the medication and witnessing its ingestion.
Pharmacy Managers
As leaders in the healthcare system, pharmacy managers play
a key role in developing and maintaining safety culture and practices in
community pharmacy. Pharmacy managers can target the order entry, dispensing,
technical check, and patient counselling steps to reduce the chances of patient
harm in their pharmacies.
Order Entry
- Enhance the use of technology (e.g., a medication synchronization program to align refill dates for a patient’s medications) to improve workflow and reduce interruptions.
- Consider incorporating TALLman lettering in the dispensing software as a differentiation strategy for look-alike medication names. The TALLman lettering will then appear onscreen and on printed labels.
- Implement a policy to inactivate discontinued prescriptions on a patient’s profile before, or immediately after, entering the new prescription.
- In the case of opioid agonist therapy, create a copy of the new prescription for the log of witnessed and take-home doses to allow for review prior to dispensing and/or administration. Start a new log with each new prescription.
Dispensing
- Post specific preparation instructions for each vaccine in the vaccine preparation area.
- Integrate bar coding technology into the pharmacy to act as an automated independent double check in the dispensing process.
- Proactively identify and prevent known workarounds (e.g., scanning one bottle multiple times); educate staff about the risks of circumventing safeguards. The most effective strategies are forcing functions that make it impossible to perform specific erroneous acts.
Technical Checks
- Require documentation of an independent double check for each critical verification step in the compounding process:
- Calculations, if required
- Identity of each active pharmaceutical ingredient (API) and excipient before mixing
- Lot number and expiry date of each API and excipient
- Weight and/or measurement of each API and excipient
- The weight can be captured for the final check via video, photograph, or printout from the weigh scale.
- A final check of the finished product has been conducted
Patient Counselling
- Consider the use of technology to support communication with patients when they are unable to pick up the prescriptions themselves.
- Facilitate electronic access to medication information resources, including Canadian product monographs and relevant practice guidelines, to allow for efficient research.
Conclusion
Pharmacy quality improvement and patient safety are the cornerstones of effective community pharmacy practice. The recommendations outlined in the ISMP Canada analysis report demonstrate that everyone in the pharmacy, from pharmacy technicians and support staff to pharmacists to management, has a vital role to play in ensuring these standards are met. Collaboration, diligence, and a commitment to following best practices at every step of the prescription processing journey are essential to providing patients with the safest and most effective medication management possible. By embracing these recommendations, pharmacies can better serve their communities and contribute to improved patient outcomes.
