Under Pressure: Tackling the Rise in Patient Safety Incidents

June 6th, 2019 | In Resources

tackling the rise in patient safety incidents

As a pharmacist, you want – above all – to help your patients. That’s what inspired you to choose this career, and that’s what keeps you going through the long days and the on-going challenges.

So the news that patient safety incidents reported to the National Pharmacy Association [Link will open PDF in new window] (NPA) rose by 29% in the first quarter of 2019 will cause concern in pharmacies across the UK.

Patient safety incidents rose by 29% in the first quarter of 2019Click To Tweet

What are the common errors? What caused them? And what might you be able to do to improve patient safety in your own pharmacy?

Common Errors

According to the NPA’s Patient Safety Update, the two most common errors were:

 – dispensing the wrong drug (33%),

 – the right drug but at the wrong strength (21%).

Some of the ‘wrong strength’ cases concerned Citalopram, where packets of different strength tablets look very similar to one another. One pharmacy learned from its mistake and segregated stock to avoid further confusion. A simple yet effective solution for a busy pharmacy team!

Wrong formulation, wrong quantity, and mismatching patients make up the top five categories of error.

Contributory Factors

But why do such mistake occur?

Sadly, the biggest single cause will be of no surprise to harried pharmacists. ‘Work and environment factors’ contributed to 34% of errors.

That includes time pressures; distractions, such as answering queries from pharmacy teams while trying to check prescriptions; and increased staff turnover, leading to fewer trained staff.

Some 15% of pharmacists said they had to self-check: that means carrying out every step of the dispensing process themselves, including the clinical and accuracy check. With such pressure on one very busy person, mistakes can – and do – occur.

And Now the Good News…

More than half of all errors caused no harm to the patient, and a further third were classified as ‘near misses’. None caused death.

Incidents categorised as causing ‘moderate’ harm dropped by 1% since the previous quarter, to 2%.

And in some cases, pharmacists’ vigilance actually prevented accidental harm to patients.

One queried a GP prescription for trimethoprim oral suspension 50mg/5ml for an infant recently discharged from hospital. It transpired that the hospital had mistakenly said the infant needed 10ml daily, whereas the correct figure for the child’s weight was, in fact, just 1ml.

Another pharmacist was puzzled by a prescription for three pre-filled syringes of REVAXIS vaccine, which is normally given as a single dose. The GP confirmed that they had intended to select the Rabipur vaccine for pre-exposure prophylaxis against rabies.

Just two examples of the excellent work done by pharmacy teams day in, day out across the country.

Reducing risk with Pharmapod Incident Management

Even the best, most conscientious pharmacist can make mistakes. But learning from those mistakes is one of the hallmarks of a great pharmacy.

Whether you work in a community, hospital or care home pharmacy setting, patient safety software like Pharmapod can be customised to your individual needs and help you drive continuous quality improvement and positive clinical outcomes.

Take the Incident Management module. This enables you to record any errors and near misses quickly and easily while the ‘My Actions’ section lists any Corrective Action / Preventative Action (CAPAs) you might need to take.

By adopting this software, pharmacists have not only seen an increase in the number of errors recorded, but they have also improved data quality and overall operational efficiencies, too.

Pharmapod has been created by pharmacists, for pharmacists – they understand that, no matter how busy you are, patient safety is still your number one priority. See what it could do for your business by talking to our team today.

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