2021 FDA Science Forum
Evaluating Medication Errors Occurring During the Outpatient Pharmacy Prescription Refill Process
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- Center:
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Contributing OfficeCenter for Drug Evaluation and Research
Abstract
Purpose
This retrospective review sought to evaluate how often medication errors occur during the outpatient pharmacy prescription refill process due to pharmacy personnel inadvertently changing the dispensed medication during a refill. Secondary objectives were to examine commonalities between medication errors occurring during the outpatient pharmacy prescription refill process as well as errors that are discovered during the outpatient pharmacy prescription refill process.
Methods
On August 22, 2020, the Institute for Safe Medication Practices Medication Error Reporting Program database was searched using the keyword ""refill"" to identify medication errors involved around the outpatient pharmacy prescription refill process. The 300 most recent reports were evaluated for eligibility. Eligible reports were assessed to determine answers to five key questions:
- What type of error occurred?
- Who identified the error?
- How/Why was the error recognized?
- Did the patient experience an adverse event(s)?
- How long did the error go undetected?
Results
Two-hundred and six error reports were included in the final analysis. The most common errors included wrong drug (30%), wrong strength (26%), and wrong directions (15%). Errors were most commonly recognized by pharmacists (44%) and patients (36%). Approximately 40% of errors were recognized during the refill process irrespective of when the actual error occurred. For example, a pharmacist reviewing a refilled medication and realizing the previous fill was incorrect would fall into this category. Nearly half of errors went unnoticed for at least one whole fill. At least one in six patients that experienced a medication error had a related adverse event.
Conclusions
Medication errors can occur at any point during the medication use process. Although patients may receive an initial fill correctly, medication errors can occur during refill. Patients play an integral part in ensuring safety during the entirety of the medication use process, and patient involvement is a key safety factor in ensuring the appropriate medications are always prescribed, dispensed, and ultimately consumed.
