Minimising Out Patient Medication Dispensing Errors In An Environment Of Low Technology Utilisation.
Seeking cost effective solutions to minimise medication dispensing errors in Out patient Scenario in the current low technology utilisation environment .
India, being a highly populated country with very low qualified human resources in healthcare is troubled and plagued with a continuous challenge of medication errors.
Medication errors are primarily divided into
- Administration errors
- Prescription errors
- Dispensing errors
The following fall under Dispensing errors.
- Wrong medicine (may be alternate drugs in case of non- availability of prescribed drug)
- Wrong quantity
- Expired medicines
While the hospital in reference could address the challenge of Administration errors and Prescription errors to a large extent through process re-engineering, the concern of dispensing errors endangering patient safety still persists.
The methodology of tracking the data of dispensing errors being – Voluntary reporting by nurses/doctors; leaves a lot to be addressed because the patients once after leaving the hospital and pharmacy post consultation, do not usually come back to the prescribing doctor / nurse owing to lack of awareness. As the patients are free to choose the doctor in Indian healthcare scenario, they typically tend to approach another doctor for improving their possible deteriorated condition owing to wrong medication (they might not be aware of the possible cause in many cases).
Indian healthcare where EMR utilization is not significant, and the data of the patient not captured, stored and shared between healthcare providers in addition to the lack of awareness in the patient makes it nearly impossible for the healthcare provider to understand and address the complications arising out of possible dispensing errors, more in Out Patient scenario.
To minimize medication dispensing errors, the following efforts have been put
- Look alike and sound alike drugs are stored separately
- High risk medicines stored separately
- All loose medications are stored in pouches with name, strength and expiry
- Double check before Dispensing medications.
Another major hurdle noticed is that in India where the patients are free to choose their pharmacy, there is higher probability of such dispensing errors (as such efforts to minimizing dispensing errors may not be implemented in the pharmacy not related to the hospital).
To understand the utilization of hospital associated pharmacy, a study was conducted (sample size of 873 prescriptions) and the results were as below ( image attached)
Certain measures were taken to encourage the patients purchase prescription from the hospital associated pharmacy. Despite the above efforts, the dispensing errors continued risking patient safety and it had been agreed that use of HIS is the only solution. When this is discussed with the doctors, there is a clear resistance owing to the reasons cited (a few)
- Use of EMR (keying into the computer) would intervene with the physician – patient eye contact as physicians are not effectively trained in using computers, resulting in a dissatisfied patient.
- Employing physician assistants for the job would increase the burden of healthcare costs.
- Physician burn out with EMR in a country where patient load is quite high.
- There is no mechanism to ensure that the patient purchases prescription in the hospital associated pharmacy despite using the current EMR.
Owing to the above scenario, the hospital is seeking solutions to increase patient safety minimizing Out patient medication dispensing errors.
Medication management was one of the most difficult areas when our first hospital went through the Joint Commission International accreditation. nevertheless, the process of setting up systems that address the medication administration and medication management was very helpful for the entire organization. Technology solutions can help with preventing errors, but they reflect actual underlying processes. In my opinion the processes should first be formulated and then technology can help in implementation. Adding secondary labels on high-risk drugs, having double verification (signature) on dispensing narcotics, writing down the various times of actual administration of a drug in a paper log, do not require technology and could be as effective as a high-tech solution.
As mentioned in the submission, we are seeking solutions in the out patient scenario. In this case, we do not dispense high risk medication or narcotics to out patients. The route of drug administration with period and interval is mentioned and the patients are educated accordingly. Our problem area is more of a dispensing error than administration error. The double verification is an effective and tried solution , but is not effective enough when huge volumes of patients crowd at the pharmacy during peak hours.
The costs of dispensing errors should be valued against a (pharmacy) nurse working through the diagnoses and medication of patients. Educating patients will decrease your dispensing errors.
We now have a system of educating patients and their caregivers concerning their medications during their hospital stay. This also deminishes the number of medication errors.
As mentioned in the submission, we are seeking solutions in the Out Patient scenario. The route of drug administration with period and interval is mentioned and the patients are educated accordingly.
Our problem area is more of a dispensing error than administration error. The double verification is an effective and tried solution , but is not effective enough when huge volumes of patients crowd at the pharmacy during peak hours.
I am sympathetic to your doctors’ resistance to the EMR. It comes at high cost, tends to decrease efficiency in many settings, and can create new types of errors. Hopefully, all that will improve someday. Perhaps pre-printing prescriptions, with standardized instructions, could help. If, later, an electronic system is implemented, it could be helpful to have these procedures already established.
Pre-printing prescriptions though is a conceivable solution , still leaves the challenge unaddressed as Indian drugs are prescribed / dispensed on various trade names than their proper drug names and each doctor has their preferred choice of drugs ( by their trade name) making it quite complex for implementation in a multi-speciality and huge set up with more than 100 doctors of various specialities attending to the out patients every day.