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A prescription for accuracy

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28 March 2011

Pharmacy

When pharmacists dispense more than 200 million prescriptions each year, there is the risk that some mistakes will occur.

A national team of researchers has investigated why dispensing errors or 'near misses' occur and how they can be reduced.

A research consortium from Monash University, the University of Sydney and the University of South Australia recently undertook a pilot study identifying the type of dispensing mistakes that are picked up before they reach the patient - known as near misses.

"For our research, 31 pharmacies across three states volunteered to share details of their near miss incidents during a three month trial via an anonymous online reporting system," researcher Dr Jill Beattie said.

During the evaluation of the new reporting and learning system, the 31 participating pharmacies recorded a total of 321 near-miss incidents. The results showed that the majority of incidents occurred during computer input (44.5 per cent), followed by product selection (18.4 per cent).

Examples of why errors occur include distraction of pharmacists and a lack of differentiation between similar sounding medicines.

One of the ways pharmacists can reduce these errors is by sharing lessons learned from near misses.

One solution was the implementation of the iSOFT Patient Safety incident management system to record near-miss incidents to assist pharmacists in implementing safer dispensing procedures.

"We modified and implemented the iSOFT Patient Safety incident management system to record near-miss incidents," Dr Beattie said.

The researchers also developed and disseminated various tools and newsletters to assist pharmacists in implementing safer dispensing procedures.

The research was funded by Pharmaceutical Defence Limited and lessons learnt were shared and feedback from participants indicated that the program was encouraging change in the workplace and that the majority of participating pharmacies would continue to use the system if it was rolled out across Australia.

The researchers from the Faculty of Pharmacy and Pharmaceutical Sciences included Professor Roger Nation, Professor Michael Dooley, Dr David Kong, Dr Jill Beattie and Barbara Dixon.