Focus on responding and learning when things go wrong

We know that pharmacy professionals are delivering safe and effective care every day through person-centred professionalism and that the majority of the 1 billion prescription items dispensed per year are supplied accurately and safely.

However, given the large volume of items dispensed, on some occasions something will go wrong. In this article, we look at the different ways the pharmacy team have managed to reduce the risk of mistakes being repeated by learning from and reflecting on errors and near misses

Things can go wrong for various reasons including human error, inadequate systems or processes, or a combination of both. In some circumstances where mistakes happen, there is a culture of fear and culpability and the threat of criminal prosecution for inadvertent dispensing errors can exacerbate the situation.

It’s important to understand the impact of these incidents and what can be done to prevent them. This is particularly relevant given the legislation to create a defence to criminal sanctions for inadvertent dispensing errors. The legislation that has been approved by Parliament provides an opportunity to look closely, in this article, at areas of best practice and how risk can be effectively managed in registered pharmacies.
 

A legal defence for unintentional dispensing errors

The upcoming legislative change will promote and encourage a culture where mistakes are reported without the current fear of criminal sanction. There is good reason to believe that this approach can create a working environment where pharmacy professionals reflect positively and are inspired to learn and improve from adverse incidents. More importantly, these changes are expected to make it safer for those receiving care by protecting, promoting and improving pharmacy services.

Our inspection decision making framework identifies the importance of recording, reporting and learning from errors and near misses. Feedback from our inspections has shown that the quality of care that people receive is improved when pharmacy professionals learn from feedback and incidents and challenge poor practice and behaviours. Through inspections we see many different ways in which pharmacy professionals, pharmacy owners and superintendent pharmacists have managed the risk of making and repeating  mistakes by learning and reflecting from errors and near misses.
 

Managing risk in the dispensing process

Evidence from our inspections has also highlighted the impact that developments in science and technology are having on pharmacy services. The greater use of dispensing robotics and the automation of supply processes demonstrates how pharmacy services have evolved. For example, we have seen how a busy pharmacy in the North-West of England has successfully introduced barcode technology to increase the level of accuracy and efficiency within the dispensary. As well as reducing the risk of dispensing errors, the changes had a positive effect on the pharmacy as a whole with dispensers and the wider team benefiting from having more time to dedicate to other important aspects of service delivery.

However, dispensing errors can also be avoided in simpler ways. We have seen how a small pharmacy in the north of England carried out trend analysis to identify the most common drugs involved in adverse incidents. The information from the analysis resulted in warning labels being placed on shelf edges with the identified stock completely segregated from other medicines. Another pharmacy chose to place a physical barrier in front of amitriptyline, which was identified as among the drugs most commonly involved in wrong strength errors. These changes compelled staff to double check the prescription before selecting the medicine. We have also witnessed how a pharmacy in the west of England made sure individual prescriptions were separated from one another by using the clips on a stand next to the labelling computer. This prevented prescriptions from being mixed together, especially for members of the same family and was in response to an incident when the wrong person’s name had been printed on the dispensing label.

The examples above highlight how error reduction can be achieved in a variety of ways. But by identifying the risks associated with each step of the dispensing process, pharmacy owners, pharmacy professionals and superintendent pharmacists can find a solution that best meets the needs of their working environment. Whilst the advancement of technology has increased the number of options that are available, it can often be the most simplest of approaches that can make the biggest impact.

Pharmacy professionals can help reduce the risk in dispensing errors from occurring and should know what procedures to follow in the event of a dispensing error. Reviewing the dispensing process and the dispensary layout, removing distractions and having a segregated area of the dispensary workbench for the dispensing process can help prevent errors from taking place. For instance, making sure that two people are involved in the dispensing process can help reduce the level of risk. Making sure that a second competent person, who was not involved in the assembly process, carries out an accuracy check can help reduce the risk even further.
 

Colette Cooknell, one of our inspectors, explains how she tackles dispensing errors which haven’t resulted in moderate or severe harm.

“One of the first steps I take when dealing with this type of event is to check when the pharmacy was last inspected. I consider whether or not a full inspection or a more targeted visit to the pharmacy is appropriate, as this can help to provide an assurance that the pharmacy already has systems in place to support the safe delivery of care to patients.

“The inspection process can also help to highlight improvements that the pharmacy team should make and encourage them to think about how they can continually review and monitor risks in the dispensing process to protect patient safety.

“Inspection visits prompted by the report of a dispensing error are often unannounced, but I may contact the pharmacy in advance to make them aware that a concern has been raised with us and to gather some additional information ahead of my visit. Patients don’t always let the pharmacy know when they have experienced a dispensing error so a call from me can sometimes be the first time the pharmacy knows a mistake has been made.

“When I speak to the pharmacy team and specific registrants involved in the error, I explain my role and that my main concerns are firstly to try to find out how the error may have happened, and secondly to understand what learning points or preventative actions have been taken (or are needed) to avoid a similar event happening again. I am particularly interested in finding out how any learning points have been or will be shared with the whole team.

“It can be a shock to find out that a dispensing error has been referred to the GPhC, particularly if the pharmacy team feel that they have resolved the matter to the patient’s satisfaction. In these cases, I encourage the team to reflect on any conversations with the patient or their representative which may have caused confusion or concern and to consider how this might be avoided in the future.”

Learning from errors and incidents

It may not always be possible to foresee all the risks and deal with them in advance. But by reflecting on incidents when they do occur, there is an increased likelihood of emerging underlying trends in the dispensing process being identified and managed. Pharmacy owners can show how they have identified and managed those risks appropriately by using risk assessments for different activities and services, and collecting information, concerns and feedback from people receiving care. It is also important to consider potential new risks before starting a new service or before making changes in technology.

We have seen the impact that errors can have on patient safety. In some tragic cases, often reported in the media, we have also seen how this can contribute to the death of a person receiving care. Errors may occur at any stage and may not necessarily happen within the pharmacy. For example, a delivery driver may deliver the wrong medicine to the wrong patient. It is therefore important that the correct procedures are in place to avoid adverse incidents from occurring in the first place. Pharmacy owners should ensure they identify and manage risks, and supply medicines and services safely to patients and people who use pharmacy services. The team should be trained and competent to perform the tasks given to them. Pharmacy procedures should be carefully considered, understood and followed by the team. Whether a pharmacy service is provided face to face or delivered to a person’s home, it is important that the pharmacist is satisfied the medicine is delivered safely. And, when incidents do occur it is crucial that any lessons are identified and acted upon so that they are not repeated.

Our standards for pharmacy professionals make clear the importance of honesty, candour and learning. In particular, they set out what we expect of pharmacy professionals when something goes wrong which can help to facilitate and promote a culture of learning and improvement. The case study below highlights how effective risk management and learning can be achieved in practice.
 

Dealing with dispensing errors: a case study

A pharmacy in close proximity to a drug treatment venue decided to provide services that reflected the needs of its locality. It decided to focus its services on providing instalment supplies of methadone and buprenorphine and needle exchange services.

The pharmacy recognised that robust procedures were required to prevent incidents from occurring and in allowing its services to be delivered effectively.

Identifying the risks associated with the services it provided, the pharmacy prepared its methadone and buprenorphine services in a well organised, secure and safe manner. Regular internal audits and reviews were carried out to ensure that the safety and wellbeing of patients was guaranteed. Near misses were recorded by the person making the mistake and were reviewed frequently to identify patterns, trends and significant risks. To minimise the risk of harm, staff received training on how to avoid needle stick injuries as part of the needle exchange service, and details of how previous adverse incidents were handled and the action taken to prevent recurrence were recorded.

Recording and analysing errors and near misses was an integral part of what the pharmacy did and not just as an add-on to its other activities.

Errors and near misses were used as opportunities to learn and make changes to processes, where appropriate. There were very few near misses recorded in the recent months, which the pharmacy manager explained was due to rigorous checking at each stage of the dispensing process, which prevented mistakes from happening. Carrying out the root-cause analysis, provided staff with relevant experience and the confidence to deal with similar incidents.
 

Find out more

• The Community Pharmacy Patient Safety Group provides a forum for community pharmacy organisations to share and learn from each other when things go wrong, as well as from other sectors and industries.
• Healthcare Improvement Scotland has produced a national approach to learning from adverse events.
• The Royal Pharmaceutical Society and APTUK have produced professional standards for the reporting, learning, sharing, taking action and review of incidents and a near miss error log and near miss improvement tool to work through near miss errors and learn from them.
• The Institute for Safe Medication Practices has produced a list of commonly confused drug names, which includes look-alike and sound-alike name pairs to determine which medications require special safeguards to reduce the risk of errors.
• NHS England and the Medicines and Healthcare products Regulatory Agency (MHRA) jointly issued a Stage 3 Directive Alert providing details on how to simplify and increase reporting, improve data report quality, maximise learning and guide practice to minimise harm from medication errors.
• A Medication Safety Risk Assessment Tool can help to identify potential safety issues associated with medicines before their introduction to clinical practice.
• The Pharmaceutical Services Negotiating Committee (PSNC) has provided information on how to report patient safety incidents.