Highlights of Evidence-based Practices to Reduce Point of Sale (POS) Errors
This article was written by APMS PSO staff in consultation with its Chief Medication Safety Officer, John M. Kessler, BS Pharm., PharmD.
The pharmacist hangs up the phone in disbelief after hearing from a long-time patient that her husband is in the hospital. He was dizzy and nauseous the night before, and when his wife looked at the Rx vial, she realized that there was someone else’s name on his prescription. The pharmacist’s gut clenches as she wonders, “ We have safety checks, how could we have given a long-time patient the wrong medication?”
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You are careful, but mistakes happen. This article will summarize four primary strategies to reduce the risk of POS errors and offers some practical suggestions to reduce the chance of an error happening in your pharmacy and reaching the patient.
Point of Sale (POS) errors are fundamentally defined as “wrong patient” errors due to a mix-up in which prescriptions are bagged and dispensed to a patient. Depending on the pharmacy’s workflow, POS errors can occur when the prescription is handed to the wrong patient or, earlier in the process. For example, when a medication is placed in the wrong patient’s bag, when medications from two or more patients are placed in the same bag, or an intended medicine is omitted from the bag and fails to be dispensed. Additional errors can occur when the bag contains the patient leaflet intended for a different patient. Also, misreading the bag, or the patient identifiers, can result in POS errors. Regardless of the cause, the safety steps to prevent and detect these errors before they reach the patient and cause harm are similar.
To reduce the chance of a medication error, integrate some of these safety tactics into your pharmacy’s workflow.
- Establish policies and procedures that focus on preventing error such as standardized workflow with built-in redundancies, checklists, and reminders
- Automation and implementation of “hard stops”
- Forcing functions that do not allow advancement of a task without additional verification steps1, including POS bar code verification prior to completing the sale/transfer to the patient. (*Forcing functions are highest on the spectrum of effectiveness while standardization of procedures is ranked moderately high in its ability to prevent errors from reaching the patient*)
The absence of standardized procedures for the pharmacist, technician, and register clerk results in the inability to expect improvement in rates of POS errors. A shared understanding among the entire pharmacy team of medication safety policies and procedures is key.
While the pharmacy may have implemented safety checks to prevent mix-ups, the effectiveness of the strategies is only as good as the overall compliance in using each check. Some questions the pharmacist could ask are below:
- Is everyone in the pharmacy aware of the safety policies and procedures?
- Are they followed, or have work-arounds and short cuts replaced them in everyday operations?
- Does the overriding culture in the pharmacy focus on safety or has a competing focus resulted in unconscious support and encouragement of shortcuts and workarounds that deviate from policies and procedures?
The pharmacy manager or safety officer could conduct discrete direct observations of the actual workflow from receipt of the prescription through dispensing/counseling, noting variations in practice or deviations from standardized procedures.
Note: Keep in mind that in this article, the use of automated technologies that link the register sale to the dispensing computer, in safety terms, is a “forcing function”. A detailed review of intake and filling errors that occur earlier in the dispensing workflow have been intentionally excluded from this brief POS review.
1. Pharmacy Times. April 1, 2007 Michael J Gaunt, PharmD The Best Error-prevention Tools for the Job
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Alliance for Patient Medication Safety © 2020
The mission of APMS® is to foster a culture of quality within the profession of pharmacy that promotes a continuous systems analysis to develop best practices that will reduce medication errors, improve medication use and enhance patient care. Pharmacies work with APMS® to look for inherent risks in the pharmacy’s workflow. Their program, Pharmacy Quality Commitment +TM (PQC+) is an interactive CQI program that provides tools and resources for the pharmacy workforce to identify, report, and analyze quality-related patient safety events. APMS is a 501 c 3 supporting organization of the National Alliance of State Pharmacy Associations.