Pharmacies today are busier than ever, and with time at a premium, it’s easy to overlook or downplay the importance of thorough medication error and good catch reporting. In fact, a recent report estimated that only 14% of medication errors and good catches are reported. This underreporting means we’re missing out on valuable data that is crucial to improving patient safety. It also leaves room for recurring errors that could result in possible patient harm.
If your pharmacy isn’t reporting at least five good catches or incidents every month, chances are, you’re underreporting. Learn more about the risks of underreporting, and common scenarios where reporting can make a big difference.
The Risks of Underreporting
Each unreported incident is a missed opportunity to identify patterns that could lead to errors. Understanding the root causes of these incidents is necessary to implement processes that can prevent them in the future.
Consistently documenting errors and good catches helps create a comprehensive record of potential issues within your pharmacy operations. By analyzing this data, you can pinpoint what led to an error and take proactive steps to prevent similar situations from occurring again. Sharing what you have learned helps others working in your location. The aggregated de-identified can be shared with others across the country as well.
Examples of Missed Reporting Opportunities
If you’re not sure where to start, here are four examples of missed opportunities to report.
1. A common example of a good catch is spotting and correcting a prescriber’s dosing error, for example, an incorrect antibiotic dose for an infant. It might feel like it’s not worth reporting since you caught it in time, or it’s simply part of your job. But without documentation, there’s no record to prevent the next occurrence⸺what if that one isn’t caught in time?
2. You discover an elderly patient is not taking blood pressure medication correctly and is at risk of either a stroke or falling due to hypotension. Do you simply correct them or document HOW this misunderstanding occurred? Was this due to something during the patient education process when the prescription was new or renewed that could be improved?
3. You speak with a patient who stopped taking her prednisone abruptly without tapering the dose. You discover that she picked up a new prednisone prescription for a cough, and despite the flag on the bag to ensure the pharmacist spoke to her, she was given the medication without a consultation about the proper way to take it or the potential side effects. She was unnecessarily put at risk of adrenal crisis, a life-threatening state. How can this be prevented in the future?
4. A patient picks up their prescription for Lamisil (a medication for toe fungus). However, due to similar-sounding names, they’re mistakenly given Lamictal (a medication to treat epilepsy or bipolar disorder). The prescriber chose the wrong one in the system drop-down. Unaware of the difference, the patient takes the medication and experiences blurred and double vision along with unsteadiness, a side effect of Lamictal. How can look-alike, sound-alike errors be prevented in the future?
How to Get Started with Reporting
If this all seems overwhelming, start small. Encourage your staff to take a few minutes to report in Pharmapod, even if it feels like a routine part of the job. Regularly review the collected data and discuss findings in team meetings to foster a culture of transparency and continuous improvement.
Effective reporting is not meant to add burden to an already busy workload; it’s about enhancing patient safety. By taking a few moments to document errors and good catches, you can safeguard your patients and strengthen your pharmacy’s operations. Start today and make a meaningful impact on patient safety.
Learn more about how you can foster an environment where staff feel safe reporting all medication errors and good catches. Catch up on episode 3 of our Safety Series webinars today!
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