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‘In Ontario, technology has almost eliminated dispensing errors’

“The UK often fails to ensure each patient receives the medication they were prescribed”

A Canada-style incorporation of technology into the dispensing process could help improve patient safety in the UK, argues Stephen Gabell

In August 2017 my wife and I emigrated to Ottawa in Ontario, Canada. We were driven out by the pharmacy funding cuts, constant changes in education and huge concern over how Brexit might impact the UK for years to come. We were also attracted to Canada by the space, the weather and the people.

Healthcare provision in Canada is the responsibility of provincial governments, so there are significant differences in pharmacists’ scope of practice between provinces. However, in Ontario, registering to practice as an overseas graduate takes around 18 months, and most of the work can be done while still in the UK. Documents need to be submitted to the Pharmacy Examining Board of Canada, before you sit your evaluating and qualifying exams.

To avoid a costly bridging course, the exams must be passed at the first sitting. Each province has its own requirements and for Ontario I did a four-week placement to demonstrate my competency to practice, once I had passed the evaluating and qualifying exams, and then sat a pharmacy law exam. I registered as a pharmacist in Ontario in February 2018 and spent a few months before that working as a dispenser.

Pharmacy practice in Ontario is reasonably close to that in England. The prescribed medicines are largely the same, most of the same medicines are available over-the-counter, vaccinations are given by pharmacists, and Ontario has its own version of medicines use reviews.

We do have to deal with health insurance however, which took some getting used to. The most impactful difference between Ontario and the UK is how technology is used in the dispensing process. Although the UK talks a good game about medicines safety with initiatives such as insulin passports, valproate pregnancy prevention and patient-held monitoring for warfarin, methotrexate and lithium, it often fails in the basic goal of ensuring each patient receives the medication they were prescribed.

Every community pharmacist in the UK will have dealt with dispensing errors. Some of these have had catastrophic consequences – in the Elizabeth Lee case and the amlodipine-amitriptyline case, to name just two.

Picking errors happen for several reasons, including poor packaging design, and many of them are caught in the dispensing process. But ultimately, they happen because dispensing in the UK relies on people to detect errors.

In Ontario, barcode scanning is a key part of the dispensing process. Shoppers Drug Mart (SDM), one of the largest pharmacy companies in Canada, introduced barcode scanning 15 years ago. Gary Baxter, a pharmacist who owns two SDM stores in Ottawa, was involved in the rollout of barcode scanning and credits it with almost eliminating picking errors.

At SDM, the dispensing process involves five stages, all done digitally: data entry, data verification, clinical verification, filling and product check. Stores are normally set up with three types of workstation to facilitate this: entry, filling and pharmacist.

Other pharmacies use similar processes. At entry, the prescription is scanned and entered into the patient file. Ontario does not have electronic prescriptions, so data entry is still a manual process. The prescribing software used by doctors is not standardised as it is in the UK, and a small number of GPs still issue handwritten prescriptions.

The prescription passes to data verification, where the pharmacist or pharmacy technician verifies that the information has been transcribed correctly from the prescription.

At clinical verification, the pharmacist does a clinical check on the prescription. Because the whole process is done on computer the patient file is only a click away, so a comprehensive, individualised clinical check can take place. Any compliance issues are automatically flagged by the software.

Once the prescription has passed clinical verification by the pharmacist, it goes back to a dispenser to be filled. A dispensing label is printed, which has a barcode on it. When the dispenser comes to fill that prescription, they scan the barcode on the dispensing label and the barcode on the stock they have pulled from the shelf.

If the wrong product has been selected, the dispenser is alerted to this and can’t proceed any further. This use of a widely available technology prevents almost all picking errors, although they can still happen if multiple boxes of a product are needed and not all are scanned, or if a dispenser overrides the system by manually entering the drug identification number.

Most medicines in Canada come in bulk packs of 100 or 500, so needing multiple packs is not as common as in the UK. After the filling stage, the products are passed on for product check. At this stage the pharmacist or registered technician scans the barcode on the dispensing label and the computer then displays an image of what the product looks like, the quantity and the patient’s name.

Barcode scanning does not eliminate all errors – transcription errors can still occur, labels can be transposed on the wrong vials and compliance packaging goes through a slightly different version of the process, which does not need barcode scanning at the filling step.

However, the use of technology that has been widely available for decades has almost eliminated picking errors in the dispensing process and made Ontario a far safer place for patients.

In over 18 months of working as a pharmacist in Ontario I can remember only a handful of picking errors reaching me at the product check stage, whereas I would have encountered a similar number in one morning in the UK.

Adopting a similar barcode scanning system in the dispensing process in the UK would involve some challenges and may require reconfiguration of pharmacies but it would be a significant upgrade for patient safety.

Stephen Gabell is a pharmacist working in Ontario, Canada. He worked as a pharmacist in the UK for Paydens from 2006-17

7 Comments

Reeyah H, Community pharmacist

This is the same idea behind one of the new PMR providers. Well guess what? Most of us are stuck in contracts and we can't switch over to this system. Also, labels can still get switched? Even if you scan the right products! Also, I'm sorry but big tubs of medicines seems dated to me. So Canada isn't ahead of it all. 

Uma Patel, Community pharmacist

Interesting article. They are one step ahead with scanning, which we will have in some form in future with FMD. But two steps behind with hand written scripts. EPS has certainly reduced a lot of errors. I wonder if the overall rate of errors in UK is any different from Ottawa

Stephen Gabell, Community pharmacist

Thanks for your comment Uma. I do get some handwritten scripts but not a huge number - there are a small number of doctors in the Ottawa area who hand write scripts, but most of the scripts are computer generated. Most of the handwritten scripts I see come from the local ED, and 80% of those are for a small number of acute meds (antibiotics, pain killers, inhalers). The prescribing software in use is not as advanced as that in the UK however.
In terms of error rate and near miss rate - and this is from my personal experience - it is significantly lower than in the UK. I do get some transcription near misses, and transposed labels, but the number of picking errors is almost zero because the software stops the dispenser if the wrong product is scanned.

David Reissner, Senior Management

Good to see picking errors almost eliminated, but nothing to be smug about if handwritten prescriptions are still being used. Handwritten prescriptions are a rich source of claims. See the Daonil case for example Dale & Appelbe's chapter on Professional Conduct.

Stephen Gabell, Community pharmacist

Hi David, the number of handwritten scripts is probably similar to the UK. There are a small number of older GPs who still hand write their scripts, but most are computer generated. I don't get any practice or district nurse scripts and the dentists, optometrists and podiatrists near me who prescribe issue computer generated scripts. My local hospital does hand write their scripts, but most of those are for the same few meds.

Benie I, Locum pharmacist

Tremendous. I'm sure he's hoping next year a very similar artricle in this publication will have an avatar stating 'technology has almost eliminated pharmacists'.

Stephen Gabell, Community pharmacist

You still need a pharmacist to make sure the script is safe and appropriate for the patient, to counsel patients and to advise on OTC meds. Registered technicians can verify the prescription has been entered correctly and can do the final accuracy check but there are not many of them around. Using available technology to aid in the dispensing process does not have any impact on the amount of work for pharmacists but it does greatly reduce the risk of giving a patient the wrong medication.

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