This column was prepared by the Institute for Safe Medication Practices (ISMP), an ECRI affiliate.
A pharmacist reported that a medication was entered incorrectly into their pharmacy dispensing system from an electronic prescription. The prescriber had ordered “mometasone 100 mcg-formoterol 5 mcg inhalation.” However, the pharmacy technician entered “mometasone 100 mcg inhalation.” Fortunately, a pharmacist intercepted the error while verifying the prescription and corrected the mistake. In their investigation, the pharmacy found that distractions likely contributed to the error. The technician who entered the prescription was completing multiple tasks at one time, including answering phone calls, assisting patients at the pharmacy counter, and helping to onboard new employees.
To minimize errors, prescribers should align electronic prescriptions with National Council for Prescription Drug Programs standards and Surescripts guidelines for accurate drug matching.
The pharmacy should also investigate why the pharmacy dispensing system may not automatically match the correct drug and strength (or other information on the prescription) and communicate issues related to the electronic prescription with prescribers and their pharmacy computer system vendor and/or internal information technology staff. Design pharmacy space and workflow to minimize distractions, especially during data entry, filling, and pharmacist verification. Borrow a concept from the airline industry and create a “sterile cockpit” at each workstation to minimize unnecessary distractions and interruptions. Designate an orientation/staff development leader and safety coaches and provide protected time for onboarding to ensure that new hires are competent in the areas and systems they are assigned to work. Ideally, ISMP recommends that those who train new staff have a reduced workload to accomplish orientation goals safely and thoroughly.