Ensuring Patient Safety: Are We Doing Everything Possible?

Patient safety has always been on the pharmacist’s agenda. Every dispensed medicine carries with it a whole set of checks to ensure that the patient gets medicines safely.

A case in point: oral methotrexate—safety checks include the following:

  • Providing patients with information before and during treatment
  • Ensuring dispensing software is updated to include the latest methotrexate alerts and prompts
  • Ensuring purchased products comply with recommendations

Findings from secondary care

All patients receiving oral methotrexate should carry a monitoring and dosage record. The UK CPA is exploring the best way to develop national reporting amongst community pharmacists. Lessons can be drawn from findings from secondary care. The National Reporting and Learning Scheme (NRLS) data include all patient safety incidents, of which about 6% relate to medicines.

Data are comparable with other studies around the world, which concluded that about 8% of medication errors occur during prescribing, 14% during dispensing and 35% at administration. Of dispensing errors, 22% were wrong doses, 21% wrong medicine and 7% wrong patient.

Drugs which are error-prone are similar in the US and the UK: insulin, heparin/warfarin, and morphine are generally among the top 10.

What does it mean for community pharmacists?

Some pharmacies are already collecting dispensing error data and this is an important resource. However, community pharmacists also can be a source of information on prescribing errors, administration errors (yes, by patients, as that is how the majority of medicines are administered).

How data will be collected and reported nationally is yet to be decided. Meanwhile, pharmacists can do the following:

  • Look at high-risk drugs and see if additional safeguards can be set up
  • Report problems with product packaging or labeling, either identified by yourselves or by patients
  • Review dispensing processes
  • Identify weak areas and build in safety steps such as checks, prompts, and reminders

Above all, be prepared to share your findings as it is through shared learning that true error-proofed systems can be devised.



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