One thing that we are learning about medication errors is that they seldom occur because of one person, but rather are a result of a series of system failures. The U.S. Pharmacopiea says that “system failures include design failures (e.g., problems with a process, task, or piece of equipment) environmental factors (e.g., physical work space), and situational factors (e.g., distractions, spontaneous emergency situations, workload, and staffing levels). Findings from USP’s MEDMARX SM program indicate “distractions” are a significant and frequent contributing factor in medication error events.”(link)

To get some perspective on medication errors and how people think about them, I highly recommend you check out the Just Culture Community site, and and especially this video. One thing you will learn is that a mistake does not occur in isolation and that there are usually multiple factors involved in an error. And, that the entire prescription filling process, the whole system needs to be examined and a risk assessment made. Pharmacists Mutual Insurance Claims Study 2000 has compiled statistics for claims made for the period 1989–1999. They found that errors and omissions are most responsible for claims made against pharmacists for malpractice. Some of the most common errors, such as wrong drug(50%) or wrong strength (25%), have not varied much over this 10-year period, probably because errors were made under a continuous and stressful workload.

The design, the environment, and the procedures that are in place within a pharmacy plays a significant role in prescription errors. For far too long, pharmacists have considered themselves as the only source of presciption errors. But, the picture is really bigger than this. The entire work environment, the job and the work hours must be taken into consideration. Michael J. Schuh, “A retail pharmacist examines the consequences of working in a fishbowl” gives a good perspective on the situation. Peter Jaret in “Special Report: Avoiding Pharmacy Errors” talks about the impact of long hours and grueling pressure.

For most of us, the design, policies, and procedures in the pharmacy, are out of our control. We walk into a pharmacy that is not of our design and we are expected to work under conditions that are not optimal for patient safety. With the ever increasing demand on pharmacies and pharmacists, it seems quite evident to me that risk assessment and risk control will come to the forefront in pharmacy. It may even force change in the design of pharmacies. Pharmacists must play a role. Why? Besides the patient, the pharmacist is most impacted when it comes to a prescription error. Another thing that pharmacists must consider is “how they work”, “how long they work”, and under what “conditions they work”. Pharmacists are not helpless puppets. They choose to step into a job. This step is a critical step. Once on a job, a pharmacist still has a responsibility to try and make the working conditions better. Better working conditions mean less prescription errors. This is why pharmacists should provide feedback to the companies that design the overall pharmacy system. It is in everyones best interest that prescription errors be reduced.