Learning From Mistakes: Lessons From Australia

June 19th, 2019 | In Resources

lessons from Australia - learning from mistakes

It’s a situation that every good pharmacy strives to avoid: an official reprimand or caution over potentially catastrophic failures in processes.

But that’s what happened in three cases in Victoria State, Australia. The owners were called up before the Victorian Pharmacy Authority (VPA) to explain a catalogue of issues.

Their errors, fortunately, did not cause harm to patients. Nonetheless, they provide a useful lesson for all pharmacists who are determined to drive up safety standards and learn from others’ mistakes.

Hazardous Substances

The first pharmacy was found to have allowed a person to undertake complex compounding as a separate business on the premises without gaining VPA approval.

There was no laboratory, no powder containment cabinet and no appropriate personal protective equipment. All of the staff were therefore exposed to hazardous substances, including hormones. Eye drops compounded there did not meet sterility standards.

What’s more, investigators found discrepancies between the recorded balance of controlled drugs and the actual stock levels.

Unauthorised Access

In the second case, a pharmacy was reprimanded for failing to restrict keys and entry devices to registered pharmacists, enabling an unauthorised member of staff to access the building alone before it had opened for business.

Although the licensee claimed the staff member had obtained the keys without their knowledge, the VPA held them liable under the Pharmacy Regulation Act 2010.

This same pharmacy had also failed to maintain a temperature data logger in the drugs refrigerator, or adequately label dose administration aids.

Unhygienic Practices

A third pharmacy received a caution from the VPA for inadequate arrangements for dealing with returned unwanted or expired medications.

There were discrepancies in controlled drugs, and some dispensed controlled drugs held for packing dose administration aids were not stored securely. The dose administration filling area was not kept clean and hygienic.

The pharmacy also failed to maintain the privacy of dispensed medicines, and confidential information was found in discarded records and containers.

Hospital Admissions

Unsurprisingly, the VPA took a dim view of these breaches of pharmacy safety.

As this blog from pharmacist Kyle Malone details, a recent Pharmaceutical Society of Australia (PSA) report found that medication-related incidents lead to approximately 250,000 hospital admissions each year.

An additional 400,000 cases seen in emergency departments are probably down to the same cause.

Yet, 50% of the harm is considered preventable.

While pharmacies were not at the root of all those incidents, they are most certainly part of the solution.

For example, many hospital admissions were due to Adverse Drug Reactions (ADRs), which occurred among patients who had been prescribed inappropriate medication.

One study cited in the report found that three-fifths of hospital discharge summaries prepared in the absence of pharmacists had at least one medication error.

Plan, Do, Check, Act

PDCA

Australia is now implementing several measures based on the principle of a Learning Health System.

One is the introduction of ‘My Health Record’: an online summary of key health information that can be accessed by patients and healthcare professionals, including pharmacists, which will allow interventions in medication safety-related events.

Another is a Plan, Do, Check, Act (PDCA) cycle-based project examining the development of a model to reduce medication errors and harm in children. Results have been promising, including a fall in actual and potentially harmful events.

Reducing Medication Errors

Pharmapod is a platform that builds on PDCA foundations and allows pharmacists to learn from any errors that occur – both in their business and beyond.

By collating anonymous data on medication errors, the Pharmapod platform contributes to the global understanding of the issues and enables pharmacists to record their continuous quality improvement efforts efficiently.

It’s easy to demonstrate the consequent improvements in patient safety and reductions in error rates, and pharmacists can share their experiences globally.

That way, Pharmapod not only helps each pharmacy improve its error record but also contributes to a global learning health system.

Find out how your pharmacy can benefit by contacting the Pharmapod team today.


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