There’s no denying the impact medication incidents have on patients can be devastating — one study found that up to 98,000 deaths occur annually in the United States as a result of medication incidents, while in Canada, it’s estimated that medication incidents contribute to approximately 28,000 deaths yearly.
Medication errors can occur at many stages in the patient care journey, from ordering the medication to the time when the patient is administered the drug, however they are most common at the ordering or prescribing stage.
Most medication errors occur due to:
- Poor communication
- Distortions (poor writing, misunderstood symbols, use of abbreviations, improper translation)
- Drug names that sound alike and medications that look alike
- Human error
Fortunately, Canada and the United States are making efforts to reduce medication incidents by increasing awareness and moving to mandatory reporting and continuous quality improvement process. In the US, currently 16 of 50 states require community pharmacies to maintain a continuous quality improvement (CQI) program to monitor and prevent errors. In Canada, a CQI program with reporting medication incidents and near-miss events is mandatory in most provinces, however the level of reporting required can vary greatly depending on the safety culture in a specific pharmacy.
No matter the location, reporting incidents and near-miss events should be mandatory for all pharmacy professionals. Consistent and detailed reporting is the best way to identify gaps in processes and implement solutions that will help minimize the risk for errors and potential patient harm occurring in the future.
And the task doesn’t need to be burdensome — leveraging the features and capabilities available in medication incident reporting platforms simplifies the process and structures collected information in a way that makes it easy for pharmacy professionals to extract and learn from data in order to course correct.
Here’s how pharmacists can improve medication incident reporting without adding hours of administrative work.
Three steps to simplify medication error and near-miss reporting
When it comes to medication incident reporting, consistency and details are key. Pharmacy professionals should strive to provide details around specific events so they can learn from them in the future. To accelerate the reporting process:
1. Review the reporting form and document how the risky situation happened
When using an incident reporting platform, review the data choices available so you know what information is required and can complete the form fields faster. When creating a report, there are three key areas you should focus on to identify how a risky situation emerged:
- What went wrong? Was the error or near-miss due to an incorrect patient, drug directions or packaging?
- When in the medication management process did the error occur? Did the error happen at the prescribing, data entry, or delivery stage?
- Why did it happen? Numerous factors can contribute to an incident or near-miss event, including missing critical information, the presence of look-alike or sound-alike drugs, or pharmacy processes not being followed due to human error, tiredness, distraction, etc.
2. Divide up the work
Don’t feel like reporting is something one person must take on alone — divide up the work across staff members and consider giving leadership roles to pharmacy technicians. Pharmacy staff can be given varying degrees of access to the incident reporting platform so they’re able to contribute as needed without seeing information that isn’t relevant to them. Including all team members in incident reporting is a great way to improve engagement and enhance accountability, important factors in helping minimize safety incidents within a pharmacy.
3. Take your time to complete, review and edit
Incident reports do not need to be completed in one sitting. Pharmapod’s medication incident reporting platform enables you to save your work, so you can come and go as time allows.
- Try to set aside 5 or 10 minutes each day to work on your reports.
- Before submitting, be sure to carefully review and edit as needed to ensure the information is as accurate and detailed as possible.
- Remember to upload supporting documents and keep track of all comments or changes within the summary.
Remember, the goal of providing thorough reports isn’t to add more work to your already busy day. By providing specific details as they become available, you’ll make it easier to identify patterns that are contributing to incidents so you can take steps to avoid them in the future.
When should a near-miss event be reported?
Near-miss events are just incidents waiting to happen. Consistently reporting near-miss events is imperative to identifying trends in the medication delivery process where improvements can be made, and implementing change to prevent them from ever evolving into safety incidents where patients could be harmed.
Though it’s ultimately up to the pharmacy manager to decide how many near-miss events will be reported, the following four criteria should always be recorded:
- The near-miss may have caused harm to the patient
- It has been a recurrent issue in the pharmacy
- Provides a learning opportunity for the pharmacy practice
- Reporting aligns with the guidance set out by the pharmacy’s Provincial regulator
As pharmacists play a more pivotal role in healthcare delivery, reporting medication incidents and near miss events is essential to maintaining patient safety. Get more great advice for simplifying the reporting process and learning from data in our on-demand webinar, Mission Impossible: Can Reporting Medication Incidents and Learning from Data be Easier?
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Ready to incorporate a medication incident reporting solution in your pharmacy or healthcare setting? Contact us today to book your custom Pharmapod demo.
Our technology is used by leading global pharmacy brands and healthcare providers. We have a proven track record of successfully enhancing pharmacy workflows, improving quality policies and systems related to medication safety.
Originally published on Think Research.
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