How to manage the practice dispensary

The running and management of the pharmacy area in many veterinary practices often falls under the remit of one of the veterinary nurses. Efficient management of the pharmacy and good stock control ensures that the right medicine is available in the right place and at the right time, and that not too much capital is tied up unnecessarily. It also protects against problems arising in the supply chain. There are many elements that need to be adhered to or taken into consideration when running the pharmacy. Learning from mistakes can be vital. Within the pharmacy it is good practice to:

• Set stock levels to allow accurate stock holding
• Have a named person responsible for stock control, this can be anyone that the veterinary surgeon feels is competent to do so
• Store medicines in a logical order and in their original packaging
• Supply a product leaflet or summary of product characteristics (SPC) with all medicines dispensed or electronic form, these can be sourced from the VMD website https://www.vmd.defra.gov.uk/ProductInformationDatabase/
• Dispense medicines with the shortest expiry date first, with good stock rotation
• Store medicines with the same batch number and expiry dates together
• Record batch numbers and expiry dates of dispensed medications on the animal/client's records

Preventing errors

How and where you place items on the shelves might seem an easy and logical thing to do, but placement is really important in preventing errors. Many practices will put their items on the shelf with some form of alphabetical ordering. The items might be sectioned into flea control, wormers, liquids, large animal and small animal. There is no best order to do this, except the order that causes the least number of errors. Monitoring errors and then trialling different systems will help to highlight the most effective system for your workplace.

Dispensing errors range from those causing a life-threatening adverse event to those having financial implications; all potentially leading to client distrust and compromised animal welfare. Errors have been noted in human medical settings to range from 0–45% of all medicines dispensed (Cheung et al, 2009). Dispensing errors include a range of mistakes (see Table 1), and do not take into consideration errors made when initially prescribing the medication. The Veterinary Medicines Directorate (VMD) publish an annual report that includes the adverse events rate, including dispensing errors. In the 2015 report there were only two reported adverse events due to dispensing errors (VMD, 2017). Diesel and Davis (2015) quoted 102 dispensing errors reported to the VMD in the period 2000–2014. These reports described adverse events after the animal was administered the incorrect medication, none included near-misses in the dispensing process. As these figures are based on errors that were noted and then reported, the overall reported error rate is lower than what actually occurs as it does not reflect errors that occurred and were not observed, or recorded. Flynn et al (2003) set up hidden cameras to quantify dispensing errors and errors in advice given during the dispensing process in human pharmacies. A prevalence of 22% error rate was noted, this included ‘near-misses’.

James et al (2009) listed medicines with similar sounding names, low staffing with high workload, interruptions and distractions and the workspace as all potential causes of dispensing errors. Aldhwaihi et al's (2016) review of 15 different studies of dispensing errors found incidences ranging between 0.015–33.5%, with reasons for errors listed as in the James et al (2009) review. The Veterinary Medicines Regulations (VMR) state that the veterinary surgeon prescribing the drug must ensure that the client is competent and has explained any warnings or potential adverse events and dosing regimens. If the medicines are to be dispensed in the same premises the prescriber must be happy that the person dispensing is competent in the process, and they must also be in a position to intervene in the dispensing process if required. If they are not in a position to intervene in the dispensing process, they must check that the product dispensed is correctly labelled (VMR, 2013). Registered veterinary nurses (RVNs) have to ensure animal and public safety as part of the Code of Professional Conduct, so even though the dispensing of medications is under the direction of the veterinary surgeon, RVNs have professional responsibilities and accountability to adhere to (RCVS, 2017). Section 6.4 of the Code states that: ‘Veterinary nurses must comply with legislation relevant to the provision of veterinary services’. This includes dispensing services and, therefore, veterinary nurses need to comply with the VMR. Being aware of the potential causes of dispensing errors is important in order to prevent them from occurring. RVNs are responsible for ensuring that they are aware of any changes or updates to any regulations or legislation. Un-like suitably qualified persons (SQPs), RVNs and veterinary surgeons are not required to undertake assessed updated learning modules on medicines legislation every continuing professional development (CPD) period (AMTRA, 2018).

Seeing practice

In order to increase understanding in how a dispensary is managed, a literature search was performed and the author also visited a local human pharmacy to see what protocols and practical tips they have in place in order to prevent dispensing errors. The suggestions from the human pharmacy included:

• Where more than one strength or size of medication is stocked, to not have these next to each other on the shelf
• Look at different brands of the same drug (stocking one brand for 50 mg and a different brand for 100 mg). The branding and trade names would be different
• Use of stickers that could be placed on boxes to highlight certain things, e.g. to give with food
• When handing over the medications to the owner, reading out the medication on the label (also stating the species, e.g. is this medication for Tyson the dog?). When reading the label out loud, it makes you view it slightly differently than just reading it
• The dispensing nurse should always ask the client to confirm the first line of their address, when handing over the medication
• Any important information should be reiterated, e.g. give with food, stop if there is any vomiting or diarrhoea. Though this must be performed by the person prescribing and is not a requirement for dispensing, it can be viewed as best practice.

All dispensing errors, including ‘near-misses', should be logged. Trends can then be noted and discussed as part of the veterinary surgeons' and veterinary nurses’ team meetings. Suggestions are taken from all staff on how to avoid these errors. Similar branding labels have been problematic and caused several dispensing errors in the practice (Figure 1).

The Food and Drugs Administration (FDA) in United States of America now uses a proprietary name review process using phonetic orthographic computer analysis (POCA) to highlight any names of drugs that might have any potential similarities in how they are pronounced (sound-alike), spelled, or appear when written in print or script (look-alike) (Stockbridge and Taylor, 2015). Chen et al (20011) identified that medicines that were in similar coloured/branded labels in similar locations can also cause issues. This has caused a ‘near-miss’ in the author's practice's dispensary with Emeprid injectable (Metoclopramide, Ceva) and Dimazon injectable (Furosemide, MSD) being next to each other on the dispensary shelf (alphabetical) and being purple in colour in 10 ml bottles. Emeprid is now kept under ‘M’ for metoclopramide, so located away from the Dimazon (Figure 2). By reviewing literature on the subject and seeing other dispensary/pharmacies the author has highlighted potential areas for error, reviewed the practice's dispensary protocol and changed working practices that will hopefully reduce errors. This process will be under continued review, as new medicines are available continually, and staff and legislative changes occur.

Barriers to implementing change

Under VMR (2013) the licensed veterinary product must be used, rather than a human generic one if one is available. This therefore limits the products that can be used, ones with differently brand names, trade names etc, and could help prevent dispensing errors. There are an increasing number of corporate veterinary groups, and within these the decisions on what medicines are stocked are normally made by the company rather than at a local level. This removes the potential for practices to stock different medicines to help prevent dispensing errors.

The RCVS Code of Professional Conduct for Veterinary Nurses states that RVNs have to inform the veterinary surgeon in charge of the case of any adverse event following the use of a medicine (RCVS, 2017). There is no statement about reporting near-misses in dispensing to the VMD. This has caused some confusion about what should and should not be reported.

Human error is at fault in dispensing errors. The human element can be removed with electronic prescribing and dispensing integrated systems, and studies have shown a reduction of up to 52% when these systems are used compared with people dispensing (Hodgkinson et al, 2017). Having a no-blame culture in practice is vital in order to conduct clinical audits and to promote preventative measures. The no-blame culture was introduced into the UK National Health Service (NHS) as a method to improve the quality of care by learning from mistakes, and putting safeguards in place to ensure they do not occur again, (Elmqvist et al, 2016).

The aim of pharmacovigilance is not only to investigate and evaluate adverse events, but undertake actions to prevent them from happening (Diesel and Davis, 2015). Clinical governance is also an important aspect of the Code of Professional Conduct for RVNs and veterinary surgeons, monitoring pharmacy ‘near-misses’ is an easily achievable clinical audit that can be conducted in practice. Reflection on these audits can help prevent these potential events in the future. By undertaking a reflective practice view on these ‘near-misses’ each individual practice can undertake steps that help in their stand- ard operating procedures (SOPs) to prevent these errors.

All of the VMD's reports are published in the The Veterinary Record. As RVNs are normally responsible for the running, stocking and dispensing of medications in veterinary practices it might be of benefit to RVNs for the VMD to also report in a veterinary nursing publication.

Stock control and disposal of medicines

Effective recording of what medicines go out of date regularly (whether passed the broached date for injectables or expired medications), can aid in better stock control. Many practices have a wastage account on their practice management system (PMS) so that expired drugs can be ‘booked out’. Some PMS will have a specific function for this. Good practice should be to monitor this and adapt stock control accordingly. Using small sized bottles of injectables can help to reduce wastage.

Conclusion

The running of the pharmacy area in veterinary practices can be very rewarding. Good management protocols are required in order to ensure good stock control, rotation of stock and in order to prevent errors from occurring.

KEY POINTS

• Record all errors, including near-misses, for your own dispensary, it will help you highlight areas where you can improve dispensing practices.
• A no-blame culture is required in order to promote reporting of errors and near-misses.
• All new staff should be made aware of your dispensary protocols.
• Running the dispensary will be very individual to the practice but seeing how others run their dispensary and control stock can give good insight and provide new ideas to improve protocols.