Recommendations to Enhance Accuracy of Dispensing Medications

Personnel to whom this applies: 1) pharmacy staff, including pharmacists and pharmacy technicians; 2) nursing staff who use automated dispensing machines/cabinets; 3) nurse managers who use pharmacy stock after hours; 3) physicians who dispense from their offices and 4) healthcare administrators/managers.

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

The Council recommends that:

  1. Prescriptions/orders should always be reviewed by a pharmacist, for accuracy and appropriateness before dispensing. Any order that is incomplete, illegible, or of any other concern should be clarified using an established process for resolving questions.
  2. Pharmacists should have access to patient profile/information/records sufficient to conduct a complete and meaningful review of any prescription/order. Pharmacists should counsel patients, conduct medication reconciliation, and other medication management services, on all prescriptions dispensed, in accordance with law and best practices, for the added purpose of providing one last opportunity to prevent an error or negative health outcome related to dispensing. If on occasion, such as in an emergency administration, it is not feasible to have a pharmacist involved, the process should include appropriate checks by other qualified health care professionals prior to administration.
  3. The dispensing area is properly designed to prevent errors. The design should promote 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 the workload1.  
  4. Product inventory is arranged to help distinguish medications from one another. This may include the use of visual discriminators such as signs or markers. This is particularly important when confusion exists regarding strengths, similar-looking labels, and names that sound or appear similar.
  5. Pharmacy staff check replenishment of regular medication stock or automated dispensing machines/cabinets (e.g., Pyxis and others) to ensure accuracy of product and precision of placement (i.e., when selecting the product, before the product leaves the pharmacy, and before placing the product in the automated dispensing machine/cabinet). Whenever possible, restocking should use error-prevention technology, such as bar-code verification to supplement manual vigilance.
  6. The pharmacy should have a standard process in place to ensure the safe and timely delivery and distribution of medications to patient care areas (e.g. use of robotic, automated, pneumatic or manual services).
  7. The pharmacy should have a standard operating procedure (SOP) that details the dispensing process for that pharmacy, including a system of checks to verify accuracy. All pharmacists and pharmacy technicians should be trained on the process and required to follow it routinely. Additionally, staff should be periodically evaluated on their SOP, and the checks should be modified as needed as determined by a robust Continuous Quality Improvement (CQI) program.
  8. Pharmacies have a fully-implemented, written SOP for a CQI program to collect and analyze data regarding actual and potential errors. Pharmacies must also ensure all personnel have been trained on the program and adhere to the SOPs for regular meetings and proper handling of error related information.

General information can be found in USP–NF general chapter <1066> Physical Environments That Promote Safe Medication Use pneumatic or manual services.

Actions/Decisions are those of the Council as a whole and may not reflect the views/positions of individual member organizations.