MEDICATION ERROR REDUCTION *

Effective Date: 
Wed, 09/15/2004
Reviewed: 
Tue, 04/24/2018
Revised: 
Tue, 04/24/2018
Policy: 

The California State Board of Pharmacy requires pharmacies and health care facilities to have a Quality Assurance program to study and evaluate prescription errors in order to prevent recurrence of such errors.

The pharmacy abides by established policies and develops new policies or systems in an effort to reduce medication errors.

Any medication error is documented on a Pharmacy Medication Error Report and Review and is reported to the Quality Management Committee. Documentation also complies with the SHS Risk Managment policy.  This information is not discoverable.

Procedure: 

The pharmacist reviews every prescription for the following: Name, Date, Drug, Dose, Quantity, Directions, Signature, and Refills.

In addition, the pharmacist reviews the patient profile for drug interactions and/or duplications etc.

Any problems or questions with drug therapy or understandability or completeness of the prescription are addressed with the prescriber prior to filling the prescription.

The pharmacist ascertains that the patient is the one listed on the prescription and is the correct patient in the pharmacy computer system.

The prescription is filled appropriately and the patient receives the prescription, the appropriate paperwork and counseling.

In the event of a medication error (Definition: any variation from a prescription or drug order not corrected prior to furnishing the drug to the patient – generic and dosage form substitutions are not errors), the Pharmacy Medication Error Report and Review is filed. That report contains the name of the patient and the prescriber, the date and the facts. The patient and the presciber are notified of the error. This report is the start of an investigation. All errors are reviewed as soon as reasonably possible, but no later than two business days from date of discovery. 

That review includes:

  1. Date, location and participants in the review.
  2. Pertinent data and other information relating to the medication error(s) reviewed.
  3. Documentation of patient and prescriber notification.
  4. Findings and determinations generated by the quality assurance review.
  5. Recommended changes to pharmacy policy, procedure, systems, or processes, if any.

The policy and plan are available and readily retrievable in the pharmacy. The records are kept in the pharmacy and retained for at least one year from creation.

The review is standardized in a format to include the above information (linked) and is presented to the Quality Management Committee periodically.

The review itself may generate changes that may be implemented immediately. Those changes are documented in the review as well.

The Quality Management Committee may also recommend changes. Implementation of those changes is documented on the review when accomplished.

See: Incident Report