The Pharmaceutical Journal Vol 267 No 7169 p504
13 October 2001

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There, but for the grace of God

By John Wilson

Consider this prescription: bendrofluazide 2.5mg om, atenolol 25mg od, nifedipine m/r 20mg od, ramipril 2.5mg od, allopurinol 100mg 1 bd, digoxin 125µg om, metformin 500mg 2 bd, gliclazide 80mg 1 bd, dothiepin 25mg 1 tds.

Now consider this pharmacy: it is in a residential area, on the same campus as the surgery which has four doctors and a registrar. The pharmacist can park in the doctors’ car park and it is not uncommon for the practice staff, including the doctors, to pop into the pharmacy. As to competition, there is a multiple about 1km away and an independent about the same distance in the opposite direction. The pharmacy staff are experienced, competent and friendly. Sounds idyllic, doesn’t it? An ideal place in which to practise pharmaceutical care and medicines management, one might think. However, let us consider the reality, for I survived a couple of days as a locum there.

The doctors are in the habit of writing repeat prescriptions for three months’ supply, and not infrequently give a patient a prescription for the full six months to last until the patient’s next review. In addition, they are unhappy at the idea of the pharmacy collecting repeat prescriptions from the surgery for dispensing, preferring that patients collect their prescription in person. Why, I know not, and nor did the dispenser. So, patients or their representatives attend in person with the prescription to be dispensed.

In the traditional high-street situation, patients will often be willing to drop off their prescription at the pharmacy, do their shopping and then collect their medicines. This gives the pharmacist plenty of time to get the prescription ready and sort out any queries.

However, this particular surgery and pharmacy were at least 500m from the shops so this helpful arrangement was not popular with the patients, who walked straight into the pharmacy from the surgery and insisted on waiting. In addition, mostly, they were not patient patients, and made it obvious by their body language that they expected a prescription to be dispensed in a matter of seconds, not minutes. “It’s only a few tablets,” was said several times, even though I pointed out that the prescriptions in front were for rather more than a few tablets. I do dispense reasonably quickly, particularly when aided by a good dispenser.

The most important aspect of dispensing is not speed but accuracy, and here is the nub of the problem. By far the majority of medicines are now in patient packs, mostly of 28 tablets or capsules, with just a few of 30. Therefore one month’s supply of the prescription I described at the beginning of this article will comprise 15 separate little boxes, each requiring a label. For three months’ supply there will be 45 boxes, and for a full six-month prescription 90 (yes, 90) patient packs. And this was not an uncommon experience at that pharmacy. I dispensed two prescriptions for 300 warfarin tablets and one for 500, all in patient packs of 28. The dispenser told me that prescriptions for 1,000 tablets of warfarin were sometimes presented.

The risk of a labelling error when dispensing this kind of prescription is only too real. It was with considerable interest, therefore, that I read the article (PDF* 50K) “Learning from medication errors” in The Journal recently (PJ, 1 September, p287). Apparently, a National Patient Safety Agency is to be set up, along with a national monitoring system for errors. Presumably this covers all errors and not just medication errors, although the article did not make this clear. One large-scale analysis of errors reported over a five-year period within hospital pharmacy showed the usual range of problems, likely to be common in community pharmacy, too, such as confusing drugs with similar names and dispensing the wrong strength of a drug.

One of the hospital pharmacists interviewed in the article drew several conclusions from the data. These included:

• Staff workload should not be excessive
• Drug names that are easily confused should be avoided
• Training is necessary to ensure the competency of staff

Let us examine these conclusions — but in reverse order. First, it goes without saying that staff must be competent. However, competence alone will not eliminate errors. This depends on constant vigilance. I remember an incident from many years ago in a hospital pharmacy, where a well-trained and an experienced technician dispensed two items — prednisolone and something else. The prescription was checked by an experienced senior colleague of mine. The patient brought the two bottles of tablets back, as both contained prednisolone tablets instead of one having prednisolone and the other containing the other drug. Fortunately no harm was done.

The question of “look-alike, sound-alike” drug names, both generic and brand, is not a new problem. Confusion of chlorpromazine and chlorpropamide, for instance, has caused several deaths over the years. But how can we as pharmacists “avoid” such names, when the prescriber is responsible for ordering the medication? Again, constant vigilance is essential.

Finally, there is the question of workload. The greatest problem, certainly for a community pharmacist, is not just the amount of work but the psychological pressure on the pharmacist from numbers of patients waiting impatiently and making their irritation felt. At one pharmacy where I worked on a part-time basis for a while, the problem of patients complaining at having to wait (even though the pharmacy was in a shopping parade) was such that I devised a card which was clearly displayed in the pharmacy. When patients complained about the waiting time, the counter staff gave them the card to read while they waited.

Prescription collection services offer convenience to the patient, in eliminating the wait while the prescription is dispensed. Much more importantly, though, they allow the pharmacist to work, if not at leisure, then at least in a more controlled manner without patient pressure.

By contrast, I spent a day in the single pharmacy in a village with two surgeries. The dispenser brought in the prescriptions from one surgery on her way to work and a district nurse going on her rounds dropped in those from the other surgery. This enabled me to work steadily and much more safely, and also allowed time for a chat with patients when they came in to fetch their medicines.

The same issue of The Journal carried an article about the idea of “number plates” for medicines — in which there would be a standard layout for medicine labels. One of the recommendations is that all manufacturers should leave a clear space to take a standard 70mm x 35mm dispensing label.

Could I add that the contents of the pack should be clearly printed above the space for the dispensing label? This would be of considerable assistance in doing the final check of the dispensed medicine before handing it to the patient.

I would like to commend both APS and Norton for their packaging. These two manufacturers do have the product name printed clearly above the label space on most, but not all, of their products. They also have the name and strength of the product clearly on the end of the boxes, making product selection from the shelves easier. Others should take note and do the same. I blessed both companies when working at the first pharmacy described above, as their packs made my final check much easier.

There are three lessons from all this:

1. Pharmacists need to be protected from the “fast-food” mentality of so many patients. This is best achieved by operating a prescription collection service for regular repeats and by encouraging patients to leave their prescriptions and collect the medicines later

2. Good packaging can go a long way towards reducing errors

3. The only real defence against dispensing errors is eternal vigilance.

John Wilson is a pharmacist based in Arnold, Nottinghamshire, who has retired and now works part-time