Magazine article Drug Topics

R.Ph.S Need Error Education, Not Fines, Says Expert

Magazine article Drug Topics

R.Ph.S Need Error Education, Not Fines, Says Expert

Article excerpt

Instead of punishing pharmacists for medication errors, state pharmacy boards should be teaching them how to avoid such mistakes in the first place, according to a patient safety advocate who believes that miscues are caused by flaws in the system, not by individuals.

Too many state pharmacy boards are in the mode of imposing fines for medication errors, said Michael Cohen, R.Ph., founder/president of the Institute for Safe Medication Practices. Speaking at a breakfast sponsored by Pharmacists Planning Service Inc. at the recent annual meeting of the American Pharmaceutical Association, he said that the boards should instead be proactively educating pharmacists about ways to prevent errors that occur over and over again.

"It's frustrating to see the same errors repeated year after year, in state after state, in pharmacy after pharmacy," said Cohen. "There's no value in fining a pharmacist or pharmacy for making an error. Very little learning comes out of it. When you focus on who made the error, that basically leaves no path but to blame the pharmacist or pharmacy. And when they are fined, it's so easy to overlook the underlying causes, and no improvement ever comes out of it."

An example of an error that has occurred repeatedly is the recent Connecticut case in which a woman died after receiving opium tincture instead of camphorated opium tincture (Drug Topics, March 18). "This is a mean mixup," said Cohen, "but the information is out there. That information should be in every pharmacy I would ask if the pharmacy board or a state senator required every pharmacy to put a special label on the drug saying, 'Warning! This is not paregoric!' Probably not, but the risk is still there for every other pharmacy patient coming in."

In addition to sharing proven error-prevention measures, pharmacy boards should require pharmacists to earn at least three continuing education credits in medication safety, Cohen said. And this should be required on an annual basis to help R.Ph.s keep up with new safety issues or new drugs that may be problematic.

State pharmacy boards share the ideological concept that future medication errors may not be prevented by punishment, said Carmen Catizone, executive director of the National Association of Boards of Pharmacy. …

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