Dispensing Errors and How to Prevent Medication Safety Risks

Medication safety is essential to achieving optimal health outcomes. As the volume of prescriptions continues to rise worldwide, understanding the types of dispensing errors that can occur – and how to prevent them – has become increasingly vital. Dispensing errors threaten patient safety, leading to unwanted and potentially severe adverse events. In many cases, these errors can result in hospitalization, long-term health issues, or even death.

The Global Challenge of Medication Errors

In March 2017, the World Health Organization (WHO) launched a global “Medication Without Harm” initiative to address medication safety. This ambitious effort aims to reduce severe, avoidable medication-related harm by 50% over five years, specifically focusing on low- and middle-income countries where the burden of medication errors is often higher.

Medication errors, including dispensing mistakes, are a leading cause of injury and preventable patient harm worldwide. According to the WHO, the economic impact of medication errors is staggering, with costs estimated at USD 42 billion annually. These errors impose significant financial strain on healthcare systems and affect clinical outcomes, compromising patient safety globally.

How Medication Errors Occur: A Look at the Medication Use Process

Errors can occur in every medication use process, from prescribing to dispensing and administration. Each stage requires multiple checks, human interactions, and technological systems, which can introduce mistakes if not correctly aligned.

The Key Steps in the Medication Use Process:

1. Prescribing: Healthcare providers sometimes prescribe incorrect drugs, dosages, or formulations due to incomplete patient information or miscommunication.
2. Transcribing: Misinterpreting the prescription during the transcription process can lead to incorrect instructions for dispensing or administration.
3. Dispensing: Errors can arise during the preparation or selection of medication, often due to look-alike or sound-alike drugs.
4. Administration: Mistakes in administering the drug, such as incorrect timing, dose, or route, pose serious risks.
5. Monitoring: Inadequate follow-up on a patient’s response to a medication can result in undetected adverse effects or drug interactions.

Dispensing Errors: A Critical Risk Point

Among the various stages, dispensing errors hold an exceptionally high level of risk. These mistakes are typically defined as “discrepancies between a prescription and the medication delivered to the patient or ward.” Dispensing errors include:

• Providing medication to the wrong patient
• Dispensing the incorrect drug
• Incorrect strength or dosage
• Errors in labeling or packaging

Examples of Dispensing Errors:

• Incorrect Medicine Name: Dispensing a drug with a similar name to the one prescribed (e.g., confusing prednisone with prednisolone).
• Wrong Dosage Form: Giving a patient extended-release tablets instead of immediate-release.
• Look-Alike, Sound-Alike (LASA) Drugs: Medications that resemble each other in name or appearance are especially prone to error. For example, providers may confuse clonidine, a blood pressure medication, with clonazepam, an anti-seizure drug.

Real-Life Case: The Dangers of Dispensing Errors

The DrugCard platform recently highlighted a tragic case of a dispensing error that underscores the need for constant vigilance in medication safety. A patient was prescribed 40 mg of furosemide—a common diuretic used to treat fluid retention and high blood pressure. However, due to a pharmacist’s error, the patient received 40 mg of gliclazide, a drug used to manage diabetes.

The error went unnoticed for three weeks, during which the patient unknowingly took gliclazide instead of furosemide. As a result, she fell into a hypoglycemic coma, was hospitalized, and tragically passed away after one week. A post-mortem analysis revealed the presence of gliclazide in the patient’s hair, confirming that the dispensing error led to fatal consequences.

The Clinical and Economic Impact of Medication Errors

Dispensing errors can have far-reaching effects on both patients and healthcare systems. Clinically, these errors may lead to adverse drug reactions (ADRs), unanticipated drug interactions, or a failure to achieve therapeutic outcomes. In severe cases, patients may experience long-term complications or require emergency care, which increases the risk of hospitalization or death.

Economically, medication errors contribute to increased healthcare costs due to extended hospital stays, additional treatments, and legal liabilities. The WHO estimates that 10% of global health expenditure is linked to patient harm, much of which can be attributed to preventable medication errors.

Strategies to Prevent Dispensing Errors

Given the complexity of the medication use process, a multi-faceted approach is needed to reduce dispensing errors and other medication-related mistakes. Prevention strategies should focus on technological solutions and human factors, ensuring systems are in place to catch the mistakes before they reach the patient.

Key Prevention Strategies:

1. Double-Check Systems: Implementing automated systems that double-check prescriptions against what is being dispensed can reduce the risk of human error.
2. Clear Labeling: Use bold, clear fonts and color differentiation on drug packaging to avoid confusion between similar-looking products.
3. LASA Drug Management: Developing specific guidelines for handling look-alike sound-alike drugs to reduce errors associated with these medications.
4. Pharmacist and Staff Training: Ongoing education for pharmacists and healthcare staff to ensure they are familiar with the latest medication safety protocols.
5. Patient Involvement: Encouraging patients to double-check their medication, ask questions, and understand the purpose and dosage of their prescriptions.

WHO’s Global Initiative for Medication Safety

The WHO’s “Medication Without Harm” initiative aims to reduce the global burden of medication errors through enhanced collaboration between healthcare providers, patients, and policymakers. The program focuses on improving safety in high-risk situations, such as during care transitions or when using high-alert medications (HAMs). By prioritizing vulnerable populations and fostering international cooperation, the initiative seeks to minimize medication-related harm worldwide.

Conclusion

Medication safety is an ongoing challenge requiring constant attention from healthcare providers, pharmacists, and patients. Dispensing errors represent a critical risk point in the medication use process, and their prevention is essential to improving patient safety outcomes. Through a combination of technological innovations, training programs, and global initiatives like WHO’s “Medication Without Harm,” we can work together to reduce the frequency and severity of medication errors. Through these collective efforts, we can minimize harm and ensure safer healthcare practices for all.