Patient Safety and Quality Assurance Study Guide for the PTCB Exam

Types of Prescription Errors

There are several types of prescription errors that can occur. It is of utmost importance that each pharmacy staff member is vigilant when preparing prescriptions for the pharmacist prior to dispensing. Always double check your work, as a simple mistake on your part has the potential to harm the patient if not caught by the pharmacist. Some pharmacies have safeguards in place, like barcode scanning, to help minimize the potential for errors. However, these safeguards are not always foolproof. It is your responsibility to have a concrete understanding of your duties and how to successfully complete them with a minimal margin of error.

Abnormal Doses

It is ultimately up to the pharmacist at the quality assurance check to validate the therapeutic appropriateness of a medication’s dosage being prescribed. However, it is beneficial for the pharmacy technician to become familiar with standard dosing, dosage forms, and routes of administration of common medications. If ever in doubt, be sure to ask the pharmacist on duty prior to data entry.

For example, morphine solution is normally stocked in pharmacies in numerous concentrations. It is used for pain conditions and is often prescribed for hospice or end-of-life care. A prescription was electronically sent to your pharmacy written as:

Morphine Sulfate 100MG/5ML oral solution
5ML by mouth every 2-4 hours as needed for hospice care
Disp: 30ML

By looking at the dosing, does it seem right for a patient, even though they are on hospice, to receive 100MG (5ML) every 2-4 hours as needed? That could equate to a total of 1,200MG/day if taken every two hours! Mistakenly, the doctor’s office who sent the prescription to your pharmacy chose the wrong concentration. They meant to choose morphine sulfate 10MG/5ML oral solution, which makes more sense.

Early Refill

Early refills are typically not an issue for non-controlled medications. The patient’s prescription insurance will typically reject the claim when the pharmacy tries to process the refill and provide the pharmacy with the next available date it can be refilled. In certain circumstances like lost medications, therapy change, or international travel, the patient’s prescription insurance will provide an override to successfully refill the prescription early. However, the patient always has the ability to pay cash for the refill if the insurance company does not grant an early refill override.

With regard to controlled medications, these cannot be refilled early by federal and state regulations, unless granted by the ordering prescriber under certain circumstances. Even when the ordering prescriber grants an early refill, the patient’s prescription insurance may still reject the claim if not deemed necessary.

Typically, pharmacies will allow a 1-2 day early fill leeway so a patient is not completely out of medication before getting a refill. It is important for a pharmacy to monitor early refill trends and notify prescribers of such to limit controlled medication misuse. Prescribers have the ability to add a do not fill until date to any and all prescriptions, which restricts the fill and/or refill of such prescription to that exact specified date. The state board of pharmacy with which you practice has the ability to fine and take lawful action against a pharmacy if there are trends of early fills/refills on controlled medications.

Incorrect Quantity

Dispensing the correct quantity of a medication is an important step of the prescription filling process. Sometimes it is not as easy as simply filling the quantity written on a prescription. It is important to note that it is legal to dispense less than the quantity authorized on a prescription, but you should never dispense more than what is written. If a patient asks to only fill 28 days of a non-controlled medication but the prescription is written for 84 days, it is legal to do so. The remaining quantity will be on file at your pharmacy until the patient decides to refill it.

In some cases, prescribers may write the abbreviation QS as the dispense quantity, which means quantity sufficient. This means that they authorize the quantity that is sufficient to cover the duration of the prescription based on what is written in the directions. Although this is not best practice, some practitioners continue to do this, typically when writing for medications in liquid form or multi-step tapers. Technicians should be comfortable with calculating days supply and sufficient quantity based on a prescription’s directions.

Incorrect Patient

It is not uncommon for two patients to have the same name listed in your pharmacy computer system. For example, if you receive a prescription for patient Barbara Smith and there are two in your computer system, look at the date of birth to differentiate the two. However, if both Barbara Smiths have the same date of birth as well, next look at the street address to select the correct patient. Be sure to add an alert note in their patient profiles to double-check patient selection so a mix-up does not happen in the future. Also, be sure to recognize suffixes at the end of a patient’s name like Jr. or Sr. as that has the potential to cause incorrect patient selection as well.

Incorrect Drug

The selection of an incorrect drug can occur at data entry or during product selection. This can occur due to negligence or when medications sound alike/look alike. For example, dexilant is a proton pump inhibitor used to treat GERD, which is commercially available in 30MG and 60MG dosages. Duloxetine is a medication used to treat a variety of conditions including depression, which is available in those dosages among others. See how the two could easily be mixed up if one was not paying attention or working too fast? It would not be good if a patient received an antidepressant instead of their heartburn medication, or vice-versa.

Calculations

Calculation Example

Prescription: Prednisolone 15MG/5ML oral solution
Take 45MG by mouth once daily for 5 days.
Quantity to dispense: QS

What is the dose/day in ML?
How many ML total would you need to dispense for this prescription?

15MG/5ML = 3MG/1ML; 45MG (each dose)/3MG = 15ML
Each dose is 15ML (45MG)
15ML daily x 5 days = 75ML total to dispense

Hygiene and Cleaning Standards

All pharmacy personnel have the potential to spread illness and infection through direct or indirect contact with medications and patients. It is incredibly important for everyone to maintain proper personal hygiene to reduce the risk of infecting patients or contaminating drug products. This includes not working when sick and being clean and well-kept when working in the pharmacy.

Handwashing

Handwashing is one of the easiest, yet most important, aspects of infection control. Always wash your hands prior to any compounding procedure or pharmacy process that involves direct contact with the drug product. This includes washing your hands prior to donning PPE in accordance with USP regulations.

Personal Protective Equipment (PPE)

As mentioned in our study guide on compounding, PPE is required for all compounding procedures and differs based on the type of compounding and the drug products being compounded. When using PPE, it is important to follow a specific order to reduce the potential of contamination. In general, you should work from “dirtiest” to “cleanest” parts of the PPE attire. For example, you wouldn’t put shoe covers on after putting on your sterile gloves. Follow the general order listed here and make sure to check the procedures outlined by your specific pharmacy.

Remove outer garments, jewelry, makeup, artificial nails, piercings, etc. before putting on any PPE.
Start with shoe and hair covers including any facial hair.
Put on a face mask or face shield.
Wash your hands with appropriate handwashing technique.
Use a compounding-specific gown.
Don sterile gloves and use alcohol to continue to sterilize your gloved hands between drug products.

Counting Trays

Counting trays and spatulas should always be cleaned regularly before use and periodically throughout the work shift. This is typically done with 70% isopropyl alcohol. This helps reduce the risk of contamination between medication products. Also, there should be a seperate counting tray and spatula for counting medications like penicillins or sulfur-containing drugs, since some patients may have an allergy to these products. This separate tray and spatulas should be cleaned before and after every use.

Countertop

Just like counting trays, the pharmacy countertop should be wiped down and cleaned regularly, if not more often, with the appropriate detergent or isopropyl alcohol. This is to prevent the possibility of contamination and minimize bacterial growth on the surface we work on each day.

Equipment

Even though the hours of pharmacy operation may vary by setting, the pharmacy’s cleanliness must be maintained in all types of work environments. The following things should be done at least daily, if not more often:

Dusting of equipment and medication storage areas
Wiping down of keyboards, phones, all working surfaces, and tools used for medication preparation and dispensing
Vacuuming or mopping the floors
Removing trash from the pharmacy work area
Cleaning patient areas (only some settings have direct patient care areas in or around the pharmacy)

Equipment like mortar and pestle, graduated cylinders, scales, balances, Erlenmeyer flasks, and even automated dispensing machines should not be forgotten but also cleaned regularly so they are ready for use when needed.