We are kicking off a Medication Safety Officer blog series on managing refrigerated medications. Each week, Network Medication Safety Officer, Jessalynn Henney, PharmD, will be answering questions related to the safety and security of storing and handling refrigerated medications. This week, we are kicking off the discussion around factors influencing medication dispensing errors.
1. What are some of the factors influencing dispensing errors?1-3
Within the dispensing step of the medication use process, there are several elements that should be considered to reduce the risk of errors. I find it is best to organize these into five main categories: Health Care Professionals, Tasks, Work Environment, Medications, and Equipment.
Start with a Plan
While all are important to consider, I want to specifically highlight Medications and Health Care Professionals. Out of the several strategies that exist to reduce the risk of an error from occurring, I recommend starting by developing a strategic plan to help standardize where medications are stored within the Automated Dispensing Cabinet (ADC).
By ensuring each medication is placed in a designated, adequate size bin with proper labeling, this helps to prevent crowded shelves and disorganization leading to “missing” medications. This especially holds true with medications requiring refrigeration, as there are unique challenges with limited space and lack of discrete pockets or bins. Factors I have included to strategically place medications within the pharmacy and patient care units are separating different route products (ex: eye drops and ear drops), Look-Alike/Sound-Alike (LASA) medications, and look alike packaging.
While not easy at times to address, I believe one of the most important factors to incorporate when reviewing processes is the element of human factors. Did you know that when a person retrieves stock from the ADC, they are automatically wired to complete this task? This means the task being completed is unconsciously performed. The movement needed to reach inside and grab a product requires very little knowledge or training.
Over time, this repetitive motion task becomes a habit, which increases the chance for erroneous selection to not be detected. For this reason, focusing on correctly stocking the product will be more effective in reducing errors. It is important to design this process along with nursing and others who will be stocking and handling the product at point of administration to ensure accuracy of product placement. If the product is placed incorrectly, this will most likely not be detected unless technology is used (i.e. Barcode Medication Administration).
In general, the same factors I just mentioned can be applied to all medications regardless of the temperature storage requirement.
New technology is making it easier to diminish risk and reduce administration errors. Helmer Scientific has partnered with BD Pyxis to provide an innovative solution for safely and securely storing refrigerated medications in single, line-item access compartments. Learn more about the solution at the link below.
Other Blogs You Might Be Interested In...
- Drug Storage Automation— Finding Solutions for your Refrigerated Products
- Seven Key Cold Storage Recommendations from USP <1079>
- GX Solutions: Why You Need Professional, Medical-grade Cold Storage
- The Ultimate Guide to CDC Vaccine Storage and Temperature Monitoring
Medication Errors: Technical Series on Safer Primary Care. Geneva: World Health. Organization; 2016. License: CC BY-NC-SA 3.0 IGO.
Safeguarding the Storage of Drug Products. Pa Patient Saf Advis. 2010. Jun;7(2): 46-51.
Institute for Safe Medication Practices. Improving Medication in Community Pharmacy: Assessing Risk and Opportunities For Change. Retrieved from: