Sharing of risk assessment findings

Pharmacy type

Hospital

Pharmacy context

The registered pharmacy is located in a private hospital. The current registerable activity includes selling P-medicines, dispensing outpatient prescriptions (approximately 3,000 prescriptions a month) and private prescriptions (approximately 30 per month).

Relevant standards

• 1.1 - The risks associated with providing pharmacy services are identified and managed

Why this is notable practice

Changes are made to help improve the safety of services. Patterns in errors and issues identified are disseminated to all staff to help minimise future risk.

How the pharmacy did this

A risk register was used to help identify potential risks and action to be taken to minimise them, for example, the team had recently identified issues around not being able to have medicines on site due to account cancellations. The team had put in place changes in the way invoices were handled/processed, including signing for invoices in internal email to confirm receipt, to mitigate these risks. Ineligibility of prescriber handwriting was another risk identified and so the team were aiming to introduce an electronic prescribing system. A medication safety information sheet was produced to highlight examples of poor handwriting, including the use of abbreviations, as well as case study examples. These sheets were displayed in the dispensary for staff to refer to. Medication safety alerts were also generated to make staff aware of particular issues or products. For example, the pharmacists had identified that a number of nurses were not aware of the difference between Oxycontin tablets and Oxynorm capsules and had created an explanatory sheet as a result.

What difference this made to patients

Improved understanding of common prescribing and dispensing risks among pharmacy staff and other healthcare professionals working at the hospital, help to reduce errors impacting on patients.