Effective use of monitoring and review mechanisms and a culture of learning from incidents.

Pharmacy type

Community

Pharmacy context

A pharmacy within a large residential area with a significant proportion of elderly customers. Approximately 10,000 prescriptions per month. Other services include: Minor Ailments Service; Methadone; Chronic Medication Service (CMS) and smoking cessation services.

Relevant standards

• 1.2 - The safety and quality of pharmacy services are regularly reviewed and monitored
• 2.4 - There is a culture of openness, honesty and learning

Why this is notable practice

The pharmacy employs good review and monitoring processes, so that the risks associated with pharmacy services are identified and managed. This includes sharing of learning from near misses across all branches.

How the pharmacy did this

A signature audit trail enabled the final checker to provide immediate feedback to staff following a near miss or incident. The near misses and incidents were recorded by staff themselves so that they could reflect on the error. The ACT reviewed all of the near misses and the findings were shared with all of the staff at regular monthly near miss review meetings so that the staff were aware of the risks and were involved in agreeing actions to avoid re-occurrences. Staff described the near miss process as being a no blame process and it was to underpin learning and to reduce risk. All of the near miss data was forwarded on to a central office where a further analysis of area data was conducted. Each pharmacy had been asked to provide their top six near miss trends and this had been analysed. The following actions had been taken in light of near miss trends across all branches:

- Red ‘select with care’ labels applied to the Quetiapine shelf as the 100mg and 200mg packaging was very similar and to the Tramadol shelf as there had been an unacceptable level of errors between the capsules and the tablets.

- Following an unacceptable level of errors by trainees they were given additional training and had also re-read the dispensing SOPs.

The pharmacy had an incident reporting process, and when a patient reported an incident, the pharmacist was expected to undertake an investigation and submit a report to the superintendent’s office. There had been a recent incident when Tramadol had been dispensed instead of Trazadone and a red ‘select with care’ label had been applied to the shelves. The dispenser had also been informed and had re-read the SOPs.

What difference this made to patients

The sharing of trends in near misses and incidents across branches enables the pharmacy to take action to reduce the risk of common errors and therefore the potential for patient safety incidents.