Author: Marketing Team

Is improving medication and patient safety a priority for your healthcare organization in 2024? Then you need a medication incident reporting tool that makes it easy to report and track good catches and errors and learn from the data to prevent future incidents. If you haven’t already implemented Pharmapod in your pharmacy or healthcare setting, here are 10 reasons why you should consider it in 2024.

1. Comprehensive Medication Incident Management

Pharmapod empowers healthcare professionals with a comprehensive incident management system. Our platform’s robust features facilitate the seamless recording, tracking, and analysis of medication incidents, enabling you to swiftly implement resolutions and preventive measures.

2. Enhanced Patient Safety Protocols

By leveraging Pharmapod, your pharmacy or healthcare team can easily bolster patient safety protocols. Pharmapod’s functionalities facilitate real-time reporting, fostering a proactive approach to identifying potential risks and mitigating them promptly.

3. Streamlined Reporting and Analysis

Pharmapod simplifies the often-complicated task of reporting and analysis. Its user-friendly interface and analytics tools enable in-depth insights into medication incidents, allowing for data-driven decisions and continuous improvement initiatives.

Related: See what one customer said about how Pharmapod helped her long-term care home enhance efficiencies, reduce workloads, and positively impact medication and resident safety. Watch the testimonial here.

4. Collaboration and Communication

Pharmapod acts as a centralized hub for all staff members to report medication errors, ensuring seamless sharing of vital information.

When safety issues are identified, staff work together to problem-solve and make improvements. This sense of collaboration positively impacts morale and inspires staff to look for additional areas where improvements can be made.

5. Regulatory Compliance and Standards

Medication incident reporting is a regulatory requirement in many jurisdictions. Reporting into Pharmapod makes the process easy for staff and ensures all relevant information is captured. Comprehensive data and reports can be generated in a few clicks to provide to regulatory authorities when needed, ensuring your pharmacy is in full compliance.  

6. Foster a ‘Just Culture’

Medication incidents and near-miss events are often under-reported – or not reported – due to fears of disciplinary action. And while mistakes might never be fully avoidable, the only way to learn and prevent them from reoccurring is through consistent reporting.

Pharmapod makes it easy for staff to report all medication issues. When honest mistakes happen, they can be treated as learning opportunities with a focus on identifying what went wrong in the process, rather than shaming or blaming the individual who made the error. When staff feel safe reporting errors knowing they will be treated as opportunities to improve, they are more likely to report regularly. As more incidents are reported, and more processes are improved, it becomes harder for staff to commit avoidable errors.

7. Data-Driven Decision-Making

To improve processes and enhance medication safety, you need to identify gaps or areas of risk that are causing issues. Harnessing Pharmapod’s analytics capabilities provides access to a wealth of data that facilitates evidence-based decision-making, empowering teams to enact targeted interventions for improved patient outcomes.

8. Efficient Incident Resolution

Pharmapod expedites incident resolution through its systematic approach. The platform’s functionalities enable efficient investigation, root cause analysis, and the implementation of corrective actions, minimizing the impact of medication incidents.

9. Enhance Staff Engagement and Retention

Providing staff with tools and technology that enable them to work more efficiently can help reduce burnout and enhance job satisfaction. When staff can easily report and discuss errors and see a clear line of sight from reporting to actions necessary for improvements, they know their efforts directly impact patient safety, which provides a sense of purpose and keeps them engaged.

10. Patient-Centric Care Enhancement

Above all, Pharmapod champions patient-centric care. By proactively managing medication incidents and prioritizing patient safety, healthcare professionals using Pharmapod elevate the standard of care, fostering a culture centred on patient well-being.

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Ready to improve medication safety in your pharmacy or healthcare setting? Book a demo today and learn how Pharmapod supports a culture of continuous improvement and unwavering dedication to patient well-being. BOOK YOUR CUSTOM DEMO TODAY.

The human element of healthcare means that mistakes can and will happen, no matter how careful we are. In pharmacies, this often results in accidental (or sometimes intentional) medication errors. Every pharmacy has medication errors, but not all are recording them. This needs to change. Consistently recording all mistakes and near-misses (aka good catches) is the most effective way to learn from errors to prevent them from happening again. 

It’s also important to remember that more recordings does not mean the pharmacy is unsafe; rather, it means the pharmacy is aware and documenting as many events as possible to identify the trends.

Regular reporting gives us the data we need to determine contributing factors, so we can make proactive improvements that will limit the risk of it reoccurring. Here are five ways that medication incident reporting can help improve pharmacy safety.

1. Identify problems earlier

When reporting medication errors/incidents and near-miss events, pharmacists and healthcare workers can easily review the data collected to identify patterns and trends in the errors. For example, are there repeated problems with specific medications or errors happening at a similar time of day? Analyzing the data helps pinpoint issues and enables us to take proactive action to prevent an incident before it happens again. By identifying problems earlier, pharmacists can develop an evidence-based approach to pharmacy safety.

2. Improve communication

Medication incident reporting helps improve communication amongst pharmacy staff, which is essential in preventing errors. When incidents are documented, it presents an opportunity for staff to discuss areas where improvements can be made. Open, transparent communication helps build a just culture, where mistakes are treated as learning opportunities, not opportunities to assign blame. Employees feel safe discussing incidents and good catches, knowing the ultimate goal is improving the overall safety of the pharmacy.

3. Enhance processes and training

Regularly reporting medication incidents and near-misses gathers the data needed to help pinpoint process errors or gaps in training programs where improvements can be made to enhance safety. For example, are errors frequently occurring after employees get distracted answering phone calls? Could processes be improved by assigning one employee to handle all incoming calls so that others can remain focused on their work? This approach to education and training can be more effective, as it targets specific areas of need rather than a generalized approach.

4. Create a culture of safety

When reporting medication errors and near-miss events into Pharmapod, employees gain a clear line of sight from reporting to actions necessary for improvements. Knowing their efforts are directly impacting processes and patient safety provides a strong sense of purpose and motivates employees to look for additional areas where safety improvements can be made.

5. Meeting regulatory requirements

Medication incident reporting is a regulatory requirement in many areas. Reporting into a platform like Pharmapod makes the process easy for staff and ensures all relevant information is captured. Comprehensive data and reports can be generated in a few clicks to provide to regulatory authorities when needed, ensuring your pharmacy is in full compliance.  

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Ready to improve safety in your pharmacy, long-term care home, or healthcare setting? Request a demo today to discover how Pharmapod simplifies medication incident reporting, reduces risk, and enhances pharmacy efficiency.

Pharmacists everywhere understand the importance of reporting medication incidents – especially when patient harm occurs – but many remain less convinced about the importance of reporting near-miss events, or ‘good catches.’

Good catches occur regularly in pharmacies when medication errors or potential safety issues are caught before they reach the patient. Most believe that because no harm actually occurred, reporting the issue might not be worth their time.

However, reporting good catches in addition to medication incidents is critical.

In many pharmacies, good catches occur more frequently than medication incidents. If they’re not reported, we’re missing a huge opportunity to learn from trends in the data that identify similar problems within the system that can be improved to eliminate the risk of future harm. Taking a few minutes to report your good catches is truly one of the most effective ways to support system changes that will improve patient safety everywhere — and help save you time and money in the long run.

For example, consider this scenario:

Drug shortages are a common problem impacting pharmacies. A shortage of the drug Altace HCT 10mg Ramipril/12.5mg Hydrochlorothiazide meant pharmacists need to change the drug to perhaps two separate drugs e.g., Ramipril 10 mg and 12.5mg Hydrochlorothiazide.

In one pharmacy, the change was mistakenly prepared as two tablets of AltaceHCT 5mg Ramipril/12.5mg Hydrochlorothiazide, but the pharmacist caught the error before it was dispensed to the patient. The pharmacist who caught the error assumed it was an isolated incident not worthy of reporting, however, because the drug shortages were occurring on a national level, similar scenarios were playing out in pharmacies across the country.

By reporting the factors that contributed to the good catch – in this case drug shortages – we’re able to collect and analyze data on both a provincial and national scale and share the findings with stakeholders and regulatory authorities who have the power to implement change.

One pharmacy reporting a good catch appears as one tree. Many pharmacies reporting the same issue makes a forest. The bigger the forest, the easier it is to see the scale of the problem and how it impacts the trees.

Reporting good catches can also make big impacts on a smaller scale and help you identify areas within your specific pharmacy that can be improved. For example, if medications are frequently confused because they look alike, could it be resolved by stocking different brands for look-alike, sound-alike drugs so they look different. Would marking them help better differentiate them?  By making small changes in your unique location, operational efficiencies are gained and reduction of duplication of work is quickly realized.

When Should Good Catches be Reported?

Remember, the goal of reporting good catches is not to add more administrative burden to your day. The goal is to help identify the root cause of problems so solutions can be proactively implemented. The more data we have, the better we can understand when and where things are going wrong.

To encourage employees to report good catches (and medication incidents), common barriers to reporting must be removed. These typically include: lack of reporting culture, absence of a reporting system, management behaviour, and fear of consequences.

It’s important to establish a just culture in your pharmacy, where reporting is encouraged. Incident and near-miss reports should always be viewed as learning opportunities, not an opportunity to shame or blame individuals. 

While it might not be feasible to report every good catch that occurs in your pharmacy, there are certain scenarios that should always be reported. These include:

1. The good catch would have caused harm had it reached the patient.
e.g., 5 units of insulin vs 50 units.

2. The problem is a recurring issue in the pharmacy.
e.g., lookalike/soundalike drugs are dispensed in error. 

3. It provides a learning opportunity for the pharmacy practice.
e.g., the incident leading to the good catch was a result of skipped steps in pharmacy processes. 

4. Reporting the issue aligns with guidance set by your provincial regulator.
e.g., near-miss event reporting is expected in Alberta, Saskatchewan, Manitoba, Ontario, New Brunswick, Nova Scotia

Tips for Getting Started

Start small – commit to reporting one or two good catches per week to get in the habit. 

Set aside 10 to 15 minutes per day – dedicate a small amount of time each day to complete reports. 

Share the responsibility – reporting doesn’t need to fall solely on the shoulders of one individual. The Pharmapod reporting platform allows for roles-based access, so certain employees can access and input information as required.

Increase communication – ask employees if they have any good catches they’d like to share. Take the time to discuss what happened, and share how future incidents can be prevented.  

Get more advice on simplifying medication incident and near-miss reporting here. 

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Simplify Reporting in Your Pharmacy

Interested in learning how Pharmapod’s industry-leading medication Incident reporting platform can simplify medication incident and near miss reporting in your pharmacy or healthcare setting? Contact us today to book your custom Pharmapod demo. 

By Carla Beaton, Pharmacist and VP of Quality Improvements and Innovations

Pharmacists across Canada fill more than 600 million prescriptions every year, and though somewhat rare, medication incidents do occur. When COVID-19 hit, it put unprecedented pressure on the industry. Virtually overnight, pharmacists were thrust to the frontlines of healthcare and overwhelmed with an influx of phone calls and visits from patients seeking reassurance, advice, and appointments for COVID-19 vaccinations and other health issues. Not surprisingly, as pressure mounted and labour shortages intensified, mistakes increased in certain areas.

A study by Safe Assured on behalf of Pharmapod analyzed data representing more than 60,000 entries of medication errors and near-miss events from 65 percent of Canadian pharmacies pre- and post-COVID-19. They found that some areas of risk remained consistent with pre-COVID reporting, but as stress and workloads intensified in pharmacies throughout the pandemic, five areas of risk significantly increased and tended to be involved when harm occurred.

Here are the five categories of contributing risk factors that occurred in Canadian pharmacies throughout the pandemic – plus actionable items for limiting risk moving forward.

1. Environmental Distractions – OVER TENFOLD INCREASE

Environmental distractions were most often caused by:

• Numerous phone calls and inquiries about COVID, vaccinations, testing, etc.
• Influx of walk-in traffic , workload higher than normal
• Interruptions
• Multitasking beyond the usual process

Actionable Item: Online booking systems and standardized website information updates can help limit or divert phone calls to the pharmacy. Assign one employee to handle phone calls each day or to screen calls which can be delegated to the appropriate person. Manage customer/patient expectations – something the restaurant industry has mastered – by displaying wait times, busier than usual times of the day, dedicated immunization or clinical service times, and by implementing call or text when ready functions, and the ability to have the prescriptions delivered at a later time.

2. Operational Processes – TENFOLD INCREASE

Operational process errors were commonly caused by:

• Communication failures
• Missing or incorrect data entry
• Lack of clarity in policies and/or policies not followed
• System failures
• Timing disconnect or failure
• Inefficient or ineffective workflows

Actionable Item : As each pharmacy operates to accommodate their clientele, it is not a one-size-fits-all answer here. Control what you can. Complete a PSSA (Pharmacy Safety Self Assessment) to identify areas of risk and set goals to improve any gaps in your pharmacy.

Identify what needs to be escalated as systemic improvements requiring more stakeholders, including government, policy makers, professional associations,  or management.

There are error prevention action plans that on the surface seem to provide the easiest and fastest solutions, however people cannot be expected to compensate for weak systems. Select high-leverage error prevention activities that are designed to fix the system, not just people, whenever possible.

Activities from highest leverage to lowest leverage include:

• Forcing functions and constraints
• Automation and computerization
• Drug protocols and standard order forms
• Independent double checks and other redundancies
• Rules and policies
• Education and information

3. Drug Related Issues – DOUBLED

Examples of Drug related errors include:

• drug shortage, back order situation, drug recalled by manufacturer, lack of inventory
• multiple concentrations of the same drug, strength not commercially available
• unclear / absent labelling
• critical drug information missing (e.g. strength, duration, area )
• dangerous/ inappropriate  abbreviations used

Actionable Item: Many of these elements are systemic and often beyond the pharmacy’s control (i.e., drug shortage / backorder / recall / strength not available / labelling ). Systemic fixes typically require outside stakeholders working toward a common goal to mitigate the risk. Pharmacies have workaround plans and procedures for people to handle this risk, however people will not eliminate the risk, only system changes can.

Concentrate on improving efficiencies you can control with workflows to avoid drug related issues. Start with measuring workflow and inventory flow to get a baseline you can work with. Implement a proper pharmacy layout so drug-related tools are at your fingertips or close to your workstation to make accessing/ordering inventory easier, addressing multiple concentrations safer, clarifying/obtaining missing information faster, and prevent unnecessary wasting of time. Automating inventory in your dispensing software provides staff time to complete other tasks and minimizes shortages you can control.

Electronic ordering of prescriptions can be programmed to avoid dangerous abbreviations and/or missing critical drug information. Work with prescribers to move to electronic ordering and have a verification check of each original, new and refill prescription.

4. Critical Patient Information Missing or Incorrect – DOUBLED

Examples of critical pieces of patient information missing include:

• medication history
• allergy information
• address
• lab values
• pregnancy status
• history of medical conditions
• information on renal or liver function

Actionable Item: It sounds simple, but when you’re feeling rushed, it’s critical to take a moment and ensure you inquire at each patient interaction about all necessary and relevant patient information. Create a checklist of essential questions to ask all patients – new and repeat – when filling prescriptions to ensure you are current with changes in their health status or location. Having an efficient workflow will reduce frustrations for both pharmacy staff and customers. Inefficient workflows result in increased wait times and can result in patients leaving the pharmacy without medication, or leaving the pharmacy without proper counselling.

5. Patient / Caregiver Education Issues – DOUBLED

Patient or caregiver education issues were most often caused by:

• Appropriate information not provided to patients or caregivers
• Lack of clarity when providing information
• Lack of understanding by patient or caregiver

Actionable Item: An estimated 60 percent of Canadian adults lack the health literacy skills needed to adequately manage their health, which can lead to difficulties comprehending medication information, misinterpretation of instructions, and/or poor adherence. Take the appropriate time to communicate effectively to ensure patients and/or their caregivers fully understand how to safely take their prescription. Work with your team to source written materials in the language your patients best understand (this could be a systems change). Study your workflow process to avoid multitasking as much as possible – this might mean delegating tasks to maximize on the scope of practice for registered pharmacy technicians and dedicating the necessary time for the pharmacist to deliver the appropriate patient and caregiver education.

Discuss the importance of improving pharmacy workflow efficiency in order to maximize pharmacist-patient interactions. As mentioned, patients who are frustrated with wait times or who do not understand what is being done for their safety behind the counter may end up leaving the pharmacy without their medication or without  counselling on how to properly take the medication, which can have dangerous consequences to their health or result in unnecessary drug waste. Waste disrupts the inventory systems and leads to further workflow issues.

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Book a demo to learn more about how Pharmapod’s industry-leading platform can support your pharmacy’s medication and patient safety goals.

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This article originally appeared on Canadian Healthcare Network. Pharmapod is a member of the Think Research family of companies.