by Carla Beaton, BScPhm, VP Quality Improvements & Innovations at Pharmapod
Medication errors are a serious problem that cost healthcare systems around the world over $42 billion USD annually and contribute to approximately two million deaths each year.
Improving patient safety and managing risks around medication errors is an obligation shared by pharmacy professionals worldwide, and thanks to reporting and continuous quality improvement efforts, we’re making great strides.
When it comes to reporting, the need for reporting medication errors is clear, especially when a patient is harmed as a result, however reporting near-miss events is just as critical.
Near-miss events are what help us identify and predict what’s going on so we can proactively incorporate change to avoid causing harm in the future.
When I discuss the importance of near-miss reporting, it’s not uncommon to hear some pushback from busy pharmacists who don’t fully see the value, or feel they can’t possibly report every near-miss that occurs. If the issue was caught before reaching the patient, they can learn from their mistake and be more careful in the future. But what if a colleague is making the same mistake, and they don’t catch it before dispensing?
This is why documenting and reporting near-miss events is so important. It gives us all the information we need to step back and look at the factors that contributed to the near miss, so we can identify gaps in processes, systems, and equipment and incorporate quality improvements across the board. A near miss not reported is the next incident.
I discussed the issue of “lack of perceived value of reporting near-miss events” in a recent webinar, Mission Impossible: Can Reporting Medication Incidents and Learning from Data be Easier?, and compared it to an interesting blog I read by Jesse McCullough that talked about the lessons of the wood stove, or, more simply, the lessons of cause and effect.
In his blog, Jesse talked about how when you put wood in the stove, it provides heat. You would never say to the stove, “when you provide heat, then I will give you wood.” To get heat from the stove, we must first provide it with something of value, in this case wood.
This analogy perfectly highlights the importance of near-miss reporting.
We cannot say “show me the value of reporting near-miss events, and then I will start doing it.” Consistently reporting near-miss events is the only way to fuel the stove so we can identify trends and problems and proactively make improvements that will prevent the potential of causing harm in the future.
Should I Report It? Four Questions to Ask Yourself
While there are regulatory requirements for reporting medication incidents, reporting near-miss events is still largely at the discretion of pharmacy managers. Though it might not be realistic to start reporting every near miss, there are certain criteria that should always be recorded. Ask yourself the following questions – if the answer is yes, report it.
1. Would the near miss have caused harm if it reached the patient/resident?
E.g., 8 units of insulin vs 80 units of insulin
2. Has it been a recurrent issue in the pharmacy?
Eg., delivery to the wrong address
3. Does it provide a learning opportunity for the pharmacy practice?
Eg., only nine percent of community pharmacists feel comfortable educating patients about oral take home cancer drugs
4. Does reporting align with the guidance set by my pharmacy’s provincial regulator?
E.g., near-miss event reporting is expected in Alberta, Saskatchewan, Manitoba, Ontario, New Brunswick, Nova Scotia
These four scenarios are a great place to start and will help you get in the habit of reporting near-miss events, while providing the ‘wood’ needed to pinpoint process problems so you can learn and implement change.
Improving Patient Safety in the Future
In recent months, I’ve been pleased to see an increase in near-miss reporting — near misses are now reported almost as often as incidents, where historically they were reported approximately half as often. While it might feel like extra work in your already busy day, I promise that taking the time to report near-miss events is worth it. It will shed light in the direction of the most important workflow process to change/improve first, and provide us all with the information we need to make things better.
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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.
Article originally published on Think Research. Pharmapod is a member of the Think Research family of companies.
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