of current medications per patient (278 medications/312 patients) were missing from the patient record, and 0.51 of medications per patient (158 medications/312 patients) were included in the record but were not currently being taken by the patient (Bedell et al., 2000). In a family medicine outpatient clinic, pharmacists evaluated 950 prescription-renewal requests for 134 medications and found that 15 percent of prescriptions (147 out of 950) were for medications the patient was taking but were not recorded in the patient’s chart (Ernst et al., 2001).

The Community or Mail Order Pharmacy

A medication procurement error led to the inadvertent use of Bicillin C-R to treat syphilis in a Los Angeles clinic (CDC, 2005). In late 1998, the clinic pharmacy received a shipment of Bicillin C-R instead of Bicillin L-A. The pharmacy continued to order Bicillin C-R until March 2004. Other errors in the community pharmacy setting have been associated with telephoned prescriptions and medication dispensing (see Table C-12).

Prescription orders are frequently given by telephone. A study published in 1990 reported that that telephone prescriptions account for over 30 percent of all prescriptions (Spencer and Daugird, 1990). Although telephone prescription errors in the community pharmacy setting have raised concern about patient safety, the committee could only find one study addressing this topic. An observational study conducted in two community pharmacies over 11 days analyzed 813 telephone prescriptions (Camp et al., 2003). The investigators found that 12.4 percent of the telephone prescriptions contained an error. The most common types of errors included prescribing medication for the wrong patient, not providing the patient’s telephone number, prescribing the wrong strength, giving the wrong directions for use, and prescribing the wrong medication.

A study conducted in one hospital-based outpatient pharmacy found the rate of dispensing errors to be 12.5 percent (1,229/9,846 prescriptions), and 1.6 percent (155/9,846 prescriptions) of the prescriptions contained

TABLE C-12 Community Pharmacy: Errors

Telephoned prescription errorsf

Percentage of telephone prescriptions containing an error— detection method

12.4 (Camp et al., 2003)—direct observation

Dispensing errors

Percentage of prescription erroneously dispensed—detection method

1.7 (Flynn et al., 2003)—direct observation

3.4 (Buchanan et al., 1991)—direct observation

12.5 (Kistner et al., 1994)—audit of filled prescriptions

24 (Allan et al., 1995)—audit of filled prescriptions



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