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The Pharmaceutical Society of Ireland Report Poor Figures Regarding Incident Management

The PSI recently published the results from their 2015 inspections which were conducted across 144 pharmacies nationwide. The results showed that only 65% of pharmacies are compliant with error reporting and incident management requirements. This indicates that almost two in five pharmacies have an absence of a culture of recording errors and do not have an effective quality management system in place. With such poor statistics, it begs the question: how can we decrease the number of medication errors if pharmacies are failing to flag these errors internally? The recording and review of errors are key elements for an effective safety culture. In the absence of a recording culture, it is impossible to identify trends or systems weaknesses or to share the learnings with your pharmacy team, improving the team’s overall performance.

Errors are inevitable. A standard part of medication safety training is the acknowledgment of human error and a reporting culture creates recognition and acceptance of our own limitations and that of our team. Recording and reviewing errors effectively, means we can put steps in place to prevent recurrence of particular events but without this recording culture, there is no mechanism to ensure continuous improvement. From the patient’s perspective, they may be forgiving if they encounter a once off mistake, depending on the severity of the incident and how the incident is handled. Making the same mistake on a second occasion is unlikely to be acceptable to any patient and signals a legitimate cause for concern. Correctly reporting errors in a timely manner means the appropriate person is alerted to the error and can intervene as early as possible to minimise any harm to the patient and provide the appropriate reassurance and follow up. It can also trigger future warnings and alerts in certain situations, for example when medicines are being dispensed that have been involved in incidents before. Patient safety needs to be the primary aim in order to reduce human harm as well as the unnecessary costs incurred. By correctly reporting all incidents and near misses it is possible to reduce the probability of medication errors occurring, which results in increased patient satisfaction.

Pharmacists can utilise certain tools in order to assist the prevention of medication errors and reduce the risk of harm. Pharmapod is an ideal system to record incidents and near misses. Using Pharmapod to record errors, enables pharmacies to analyse errors and identify opportunities for quality improvements and system changes. Based on the recent reporting from the PSI it is clear that there needs to be a change in culture within the sector. Pharmapod intends to drive this change, by empowering pharmacy teams with effective tools including an incident management system to decrease the number of errors that occur. This will result in an increase in patient safety and quality of customer service, helping improve customer experience and loyalty in the long term.


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