Mohamed Issa, PhD (Uppsala, Sweden)
Associate Professor of Pharmaceutics
Head of Pharmacy Practice Department (PPD)
Faculty of Pharmacy, Beirut Arab University (BAU)
Medication Errors:
Despensing
Mohamed Issa, PhD (2022)
Medication Management (use) System
Prescribing
Monitoring
Transcribing
Administering
Dispensing
Mohamed Issa, PhD (2022)
Bates, et al. JAMA. 1995
Major Areas for Medication Errors
Medication Errors Reporting Program US
Mohamed Issa, PhD (2022)
Medication Management (use) System
Mohamed Issa, PhD (2022)
Prescribing Process: The 5 Rights
Mohamed Issa, PhD (2022)
Dispensing Errors: Top 3
• Dispensing incorrect medication, dosage strength, or dosage form
• Dosage miscalculations
• Failure to identify drug interactions or contraindications
Mohamed Issa, PhD (2022)
Dispensing Errors: Classification
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Commission/omission
Mechanical/Judgmental
Slip/Mistake
Potential/Actual
Mohamed Issa, PhD (2022)
Dispensing Errors: Classification
Commission/Omission
• Dispensing the wrong drug or dose would be an error of commission.
• Failure to counsel a patient or screen for drug interactions would be
considered an error of omission.
Mohamed Issa, PhD (2022)
Dispensing Errors: Classification
Mechanical/Judgmental
• Mechanical errors are those which occur during the preparation and
processing of a prescription.
• Judgmental errors, on the other hand, are those involving patient
counseling, screening, or monitoring.
Mohamed Issa, PhD (2022)
Dispensing Errors: Classification
Slip/Mistake
• Slips are often caused by distraction. An error related to reliance on
automatic behavior, after a distraction has occurred or poor system
design, would be considered a slip.
• An error due to conscious deliberation, perhaps because of a lack of
knowledge, would be considered a mistake. For example, a mistake
may occur if a pharmacist does not know that there are 2 strengths of
Prozac® available.
Mohamed Issa, PhD (2022)
Dispensing Errors: Classification
Potential/Actual
• Potential errors are those which are detected and corrected prior to
the administration of the medication.
• Actual errors are those which actually reach the patient.
Mohamed Issa, PhD (2022)
Dispensing Errors: Common Causes
• Work environment:
 Workload
 Distractions
 Work area
• Use of outdated or incorrect references
Mohamed Issa, PhD (2022)
Combating Dispensing Errors: Strategies
(1) Improve Work Load
• Ensure adequate staffing levels
• Eliminate dispensing time limits (quotas)
Examples of limiting workload:
 Dispense ≤150 prescriptions per pharmacist per day
 Require meal and rest breaks every 2–3 hours
Mohamed Issa, PhD (2022)
Combating Dispensing Errors: Strategies
(2) Control distractions
• Prohibit distractions during critical prescription-filling functions
• Centralized filling operations
• Train support staff to answer the phone
Mohamed Issa, PhD (2022)
Combating Dispensing Errors: Strategies
(3) Improve working area
• Separate by route of administration
• Reduce Clutter
 Ensure adequate space
 Store products with label facing forward
• Enhance lighting and control noise (TV, radio)
Mohamed Issa, PhD (2022)
Combating Dispensing Errors: Strategies
(4) Maintain a well-designed drug storage
• Label facing forward
• Separate by route of administration
 Agents for external use not stored with oral medications
• Mark and/or isolate high-alert drugs
• Separate sound-alike/look-alike drugs
Mohamed Issa, PhD (2022)
Combating Dispensing Errors: Strategies
(5) Adopt good dispensing practices
• Assess prescriptions for:
 Clarity: illegible handwriting, nonstandard abbreviations, missing
information
 Drug interactions and allergies
 Appropriateness of medications and dosage: Highlight unusual dosage
form or strength
• Ensure independent double checks
Mohamed Issa, PhD (2022)
Combating Dispensing Errors: Strategies
(6) Adopt useful technologies (pharmacy management software)
• Pharmacy management software
• Automated dispensing cabinets (ADCs)
• Limitations?
Mohamed Issa, PhD (2022)
Pharmacy Informatics
Mohamed Issa, PhD (2022)
Pharmacy Informatics
• The scientific field that focuses on
medication-related data and
knowledge within the continuum
of healthcare systems
Mohamed Issa, PhD (2022)
Pharmacy Informatics: Technologies?
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Automated Dispensing Cabinets
Bedside Bar Coding
Computerized Provider Order Entry (CPOE)
Electronic Medication Administration Records (eMARs)
E-Prescribing
Inventory Management Systems
Robotic IV Automation
Smart Pumps
Telepharmacy
Mohamed Issa, PhD (2022)
Pharmacy informaticist?
• All pharmacists use informatics to some degree.
• Pharmacy informaticists apply medication management
expertise to the design and development of disciplinespecific systems and software.
Mohamed Issa, PhD (2022)
THANK
YOU
Mohamed Issa, PhD (2022)
!
Mohamed Issa, PhD
2018