Missing medication, dosing errors and more: ISMP Canada on mistakes from using central fill pharmacies
Many community pharmacies use central fill pharmacies to save time and money. However, according to ISMP Canada (ISMPC), using them to fill prescriptions without the right processes can lead to confusion and safety issues.
In a new safety bulletin, ISMPC shared an analysis of incidents relating to central fill pharmacies and suggested standardized processes, quality checks and communications that can prevent errors.
Central fill pharmacies are often used to refill medications, compound prescriptions and prepare patient compliance packages. Patients give prescriptions to their pharmacies (called “originator pharmacies”), which submit batch-fill orders to central fill pharmacies. The central fill pharmacies then fill the prescriptions and send them back to the originator pharmacies, which dispense them to the patient.
In the multi-incident analysis, ISMPC looked at 185 incidents submitted between July 1, 2021, and June 30, 2023.
The top errors related to central fill pharmacies were incorrect/dose frequency (69 incidents), omitted medication/dose (48 incidents), incorrect medication filled (24), an incorrect quantity prepared (22) and incorrect prescriber on the label (5).
Only 2% of the incidents harmed patients, and that harm was mild. The other 98% were concerns, near misses, or no-harm events.
Submissions are top mistakes
ISMPC sorted the errors into three buckets: Order submission errors to central fill pharmacies, automated filling process workarounds in central fill pharmacies and system limitations.
Order submission errors were the leading cause of mistakes, making up 46% of those reported. These included mistakes in the orders sent from the originating pharmacy, known as batch-fill orders, which created issues like filling discontinued prescriptions or missing new medications.
Pharmacists using complex software to submit batch fills and not having structured processes around updating patients’ medication profiles before sending batch fill orders made issues more likely, the ISMPC said.
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Another common point where errors occurred was when a healthcare provider made changes after the originating pharmacies had sent the batch fill order.
The ISMPC found errors that included filling discontinued prescriptions and missing newly prescribed medications, some of which made their way to patients. That included a case where a healthcare provider changed a patient’s fluoxetine prescription to sertraline. The originator pharmacy told the central fill pharmacy about this, but it was too late to make the change.
Unfortunately, the originating pharmacy didn’t know that the central fill pharmacy hadn’t made the change and didn’t catch it on their checks. The patient ended up receiving the wrong medication.
In another case, the originating pharmacy simvastatin failed to include a prescription for simvastatin in a batch order. The central fill pharmacy didn’t fill it, and the originator pharmacy didn’t catch the mistake. The patient didn’t have the simvastatin in their compliance packs for a month.
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Workarounds create room for errors
Nearly as many errors came from automated filling process workarounds in the central fill pharmacies.
With strong supporting processes, automated filling processes, including automatic pill counting and machine labelling prescription bottles, reduce filling errors and improve error detection.
However, workarounds—where standard procedures are changed—can lead to mistakes. Workers might skip a safeguard because they have heavy workloads, don’t understand their importance or feel complacent thanks to the automation.
In one incident reported to ISMPC, a central fill pharmacy employee accidentally refilled an automation canister with 20 mg rivaroxaban tablets instead of 15 mg tablets. The employee skipped scanning the bar code on the medication bottle before filling and inserting the canister into the automated dispensing machine. The pharmacy packaged the higher-strength tablets into orders for three weeks before discovering the mistake.
Another issue was system limitations, which made up 10% of the errors found. Those issues included corporate formulary restrictions that prevented some medications from being provided. Downtime at originating pharmacies also led to inaccurate information being submitted to the central fill pharmacies, and downtime at central fill pharmacies led to filling delays.
Safer solutions for originator pharmacies
The report included tips for originating pharmacies.
They should create and use a checklist for submitting batch fill orders, and after they receive the product, pharmacists or regulated pharmacy technicians should do a final check against the patient profile—not the batch fill list—to catch mistakes.
To guard against mistakes made by the central fill pharmacy, staff should check that the medications they receive from central fill pharmacies are what they expected, including their number, names and strengths.
To avoid mistakes that come from system limitations, they should have standardized processes around identifying, filling and checking partially filled blister packs, software that stops orders for products that aren’t available from being sent to central fill pharmacies, and contingency plans if outages or downtime will delay the transmission of orders or deliveries from central fill pharmacies.
Better practices for central fill pharmacies
For central fill pharmacies, tips included removing compliance packs from the batch if post-submission changes are required, creating a system to tell originator pharmacies in writing about changes that are accepted or can’t be done and developing standard operating procedures for each technology-supported process. They should also standardize how they identify and package partially filled blister packs, have contingency plans or standard procedures for downtime or outages, and make sure to do standardized maintenance procedures for automated systems to lower the risk of downtime happening.
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