Patient Safety and Quality Assurance Study Guide for the PTCB Exam

Types of Prescription Errors

Prescription errors can take many forms. 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 complete them with minimal errors.

Incorrect Dose

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 the routes of administration of common medications. If ever in doubt, be sure to ask the pharmacist on duty prior to entering the data.

For example, morphine solution is normally stocked in pharmacies in various concentrations. It is used for pain conditions and is often prescribed for hospice or end-of-life care. Now, suppose the following prescription was electronically sent to your pharmacy:

Morphine Sulfate \(100 \text{ mg}/5 \text{ mL}\) oral solution
\(5 \text{ mL}\) by mouth every \(2–4\) hours as needed for hospice care
Disp: \(30 \text{ mL}\)

By looking at the dosing, does it seem right for a patient (even one in hospice care) to receive \(100\) milligrams (five milliliters) every two to four hours as needed? That would equate to a total of \(1\text{,}200\) milligrams per day if taken every two hours!

What most likely happened is that the doctor’s office that sent the prescription to your pharmacy chose the wrong concentration. They meant to choose morphine sulfate \(10\text{ mg}/5\text{ mL}\) oral solution, which makes more sense.

Early Refill

Early refills aren’t a common issue with non-controlled medications. The patient’s prescription insurance will typically reject the claim when the pharmacy tries to process the refill, providing 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 narrow 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 an early fill leeway of one to two days 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. Your state’s board of pharmacy can 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 stands for “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 the 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. When that happens, you should first look at the date of birth to ensure you have the correct patient. In rare instances, two patients with the same name can have the same date of birth as well. In such cases, look at the street address to select the correct patient. Also, be sure to take notice of suffixes at the end of a patient’s name (e.g., Jr. or Sr.), as that is another method to help you avoid selecting the wrong patient.

When you notice this situation, be sure to add an alert note in the patients’ profiles to remind others to double-check patient selection so a mix-up does not happen in the future.

Incorrect Drug

The selection of an incorrect drug can occur during data entry or product selection. This can be the fault of negligence, or it might happen when medications sound or look alike. For example, Dexilant is a brand name proton pump inhibitor (dexlansoprazole) used to treat GERD, which is commercially available in \(30\)-milligram and \(60\)-milligram dosages. Meanwhile, duloxetine is a medication used to treat a variety of conditions, including depression, which is available in the same dosages (among others). The similarity in their names means the two could easily be mixed up if one were not paying attention or working too fast. It would be bad if a patient received an antidepressant instead of their heartburn medication, or vice versa.

Incorrect Route of Administration

The route of administration is the way a medication should be properly administered. Essentially, it is the route by which a medication enters the body. This route can affect multiple factors of the medication, including absorption rate, onset of action, and therapeutic duration. For example, a medication administered by an intravenous route (into the vein) enters the bloodstream and provides its therapeutic effect faster than a medication taken orally. Certain medications can be administered by multiple routes, while others may only have a single route of administration.

Every prescription must have a valid route of administration so the patient knows how to take their medication safely and effectively. A prescriber will write it out on the prescription or use Latin shorthand abbreviations to convey the route of administration.

These are the most common shorthand abbreviations for routes of administration:

PO—by mouth (orally)
IV—intravenously
IM—intramuscularly
SUB-Q/SQ—subcutaneously
PR—per rectum
PV—per vagina
TOP—topically
IN—intranasally
INH—inhalation
OS/OD/OU—left eye/right eye/both eyes
AS/AD/AU—left ear/right ear/both ears

Administration Errors

Insulin should be administered subcutaneously (SUB-Q). Administering it intramuscularly (IM) would affect its rate of absorption and could cause hypoglycemia.
Most vaccines (e.g., Afluria) are administered intramuscularly (IM). They are not designed to be given intravenously (IV) and should never be given by that route.
Some inhalers come in dry powder formulation. A capsule of the medication must be inserted in the dry powder inhaler (DPI) properly before the medication is inhaled. These capsules could mistakenly be taken by mouth (PO) if the prescription directions do not specify the route of administration or if the patient is not counseled by the pharmacist. For example, proper directions on a prescription for Spiriva Handihaler (a DPI) should read as such: “Inhale the contents of one capsule once daily using the Handihaler device.”
Ear drops are not sterile and should never be administered in the eye. However, eye drops are sterile and, in some cases, may be prescribed off-label to be administered in the ear.

Calculations

A key part of your job is being able to do calculations, in part because it helps to prevent errors. Consider this prescription below:

Prednisolone \(15\text{ mg}/5\text{ mL}\) oral solution
Take \(45\text{ mg}\) by mouth once daily for \(5\) days
Quantity to dispense: QS

What is the dose per day in milliliters? Furthermore, how many milliliters total would you need to dispense for this prescription?

Let’s do the basic calculations:

\[15\text{ mg}/5\text{ mL} = 3\text{ mg}/1\text{ mL}\] \[45\text{ mg}/3\text{ mg} = 15\text{ mL}\]

Therefore, each daily dose is \(15\) milliliters (\(45\) milligrams), which lets us determine the total dosage to dispense in milliliters:

\[15\text{ mL} \times 5 = 75\text{ mL}\]

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 your personal protective equipment in accordance with USP regulations.

Personal Protective Equipment (PPE)

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 the shoe and hair covers, including any facial hair.
Put on a face mask or face shield.
Wash your hands with an appropriate handwashing technique.
Use a compounding-specific gown.
Don sterile gloves and use alcohol 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 separate counting tray and spatula for counting medications like penicillin or sulfur-containing drugs, since some patients may have an allergy to these products. These separate trays 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 with the appropriate detergent or isopropyl alcohol. This is to prevent the possibility of contamination and minimize bacterial growth on the surfaces you 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:

Dust equipment and medication storage areas.
Wipe down keyboards, phones, all working surfaces, and tools used for medication preparation and dispensing.
Vacuum or mop the floors.
Remove trash from the pharmacy work area.
Clean patient areas (only some settings have direct patient care areas in or around the pharmacy).

Additionally, do not forget equipment like mortars and pestles, graduated cylinders, scales, balances, Erlenmeyer flasks, and even automated dispensing machines. Be sure they are cleaned regularly so they are ready for use when needed.