NCC MERP -- Recommendations for Avoiding Error-Prone Aspects of Dispensing Medications

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Recommendations to Enhance Accuracy of Dispensing Medications

Adopted March 19, 1999
Revised June 2, 2005

Personnel to whom this applies: Pharmacy staff including pharmacists and pharmacy technicians; Nursing staff that utilize automated dispensing machines/cabinets; Nurse Managers that utilize pharmacy stock after hours; Health care administrators/managers.

Technology plays an important role in the delivery of healthcare. Utilize technology, as appropriate, but evaluate its effectiveness on an ongoing basis. While technology can reduce medication errors and enhance patient safety, it also has the potential to cause new types of unintentional errors.

The Council recommends:

...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.

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

...the dispensing area be properly designed to prevent errors. Design should address fatigue-reducing environmental conditions (e.g. adequate lighting, air conditioning, noise level abatement, ergonomic fixtures); minimize distractions (e.g. telephone and personnel interruptions, clutter, unrelated tasks); and provide sufficient staffing and other resources for workload.

...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 names that sound or appear similar.

...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 (e.g. bar coding systems), computer systems, and patient profiles.

...labels be read at least three times (e.g., when selecting the product, when packaging the product, and when returning the product to the shelf).

...pharmacy staff triple check replenishment of regular medication stock or automated dispensing machines/cabinets (e.g., Pyxis, etc) to ensure accuracy of product and precision of placement (e.g., when selecting the product, before the product leaves the pharmacy, and prior to placing the product in the automated dispensing machine/cabinet).

...pharmacists counsel patients at the time of dispensing. Counseling should be viewed as an opportunity to verify the accuracy of dispensing and the patient's understanding of proper medication use. Counseling should include:

Indications for the use of the medication as well as precautions and warnings;

Expected outcome from the medication;

Potential adverse reactions and interactions with food or other medications;

Actions to take when adverse reactions or interactions occur; and

Storage requirements of the medication.

...pharmacies collect and analyze data regarding actual and potential errors for the purpose of continuous quality improvement (e.g., provide feedback to local prescribers, provide error information to national reporting programs/databases).

...both initial and ongoing training of pharmacy staff on accepted standards of practice related to accurate dispensing processes with the ultimate goal of medication error reduction.

...each pharmacy establish policies and procedures for the medication dispensing process. This will ensure that all personnel, including pharmacists, support staff, and relief staff, are informed of expectations related to the dispensing process.

© 1998–2008 National Coordinating Council for Medication Error Reporting and Prevention. All Rights Reserved. *Permission is hereby granted to reproduce information contained herein provided that such reproduction shall not modify the text and shall include the copyright notice appearing on the pages from which it was copied.