We`ve seen the impact mistakes can have on patient safety. In some tragic cases, which have often been reported in the media, we have also seen how this can contribute to the death of a person being treated. Errors can occur at any time and do not necessarily have to occur within the pharmacy. For example, a delivery driver may deliver the wrong medication to the wrong patient. Therefore, it is important that the right procedures are in place to avoid unwanted incidents in the first place. Pharmacy owners should ensure that they identify and manage risks and safely provide drugs and services to patients and people who use pharmacy services. The team must be trained and competent to carry out the tasks assigned to it. Pharmaceutical procedures should be carefully reviewed, understood and followed by the team. Whether a pharmacy service is provided in person or in a person`s home, it is important for the pharmacist to be confident that the medication is delivered safely. And when incidents do occur, it`s crucial that all lessons are identified and implemented so they don`t happen again. Why medical distribution is important for safety: It is important to understand the impact of these incidents and what can be done to prevent them.
This is particularly relevant given the legislation establishing a defence against criminal sanctions for accidental submission errors. The legislation adopted by Parliament provides an opportunity in this article to examine in detail the areas of good practice and how risks can be effectively managed in licensed pharmacies. We searched Pubmed online using the keywords `exit error` and related search terms. We also handsearched reference lists of retrieved and selected studies for related articles. We only used studies published in English after 2003. Our portable system reviews patients` medication histories and automates compliance checklists to reduce human error in medication administration and administration. The application of the ubiquitous mobile device in healthcare creates a platform that dramatically improves medication safety while reducing costs. Most studies examined dispensing errors in hospitals in the US or Europe from the perspective of the pharmaceutical chain of care to patients (i.e. without prescribing and administration errors).
There is less research on community pharmacies or mail order pharmacies. Dosing error rates were low to very low. Nevertheless, it is still necessary to pay attention to dispensing errors, as pharmacies today dispense such high quantities of medicines that even a low error rate can lead to a large number of errors . Pharmacists can help reduce the risk of dispensing errors and should know what procedures to follow in the event of a prescription error. Checking the dosing process and pharmacy layout, eliminating distractions, and having a separate area of the pharmacy workbench for the dispensing process can help prevent errors. For example, ensuring that two people are involved in the filing process can help reduce risk. Ensuring that a second competent person who was not involved in the assembly process performs an accuracy check can help further reduce the risk. “Inspection visits triggered by a dispensing error report are often unannounced, but I can contact the pharmacy in advance to notify them that a concern has been raised with us and to gather additional information prior to my visit. Patients don`t always inform the pharmacy when they`ve experienced a prescription error, so sometimes a call from me can be the first time the pharmacy knows a mistake has been made. The results of our inspections also highlighted the impact of scientific and technological advances on pharmaceutical services. The increased use of dosing robotics and the automation of procurement processes show how pharmaceutical services have evolved. For example, we saw a busy pharmacy in the North West of England successfully adopt barcode technology to increase pharmacy accuracy and efficiency.
The changes not only reduced the risk of dispensing errors, but also had a positive impact on the pharmacy as a whole, as donors and the entire team were given more time for other important aspects of service delivery. Some studies have used a self-reporting system to count the number of submission errors. These studies did not find an error rate because the total number of drugs dispensed was unknown because it used a reporting system that only counted the number of dispensing errors without measuring a denominator [12, 13]. Due to differences in study design, it was difficult to compare reported rates of errors of delivery directly between studies. The researchers used different operational definitions of dispensing errors and also different denominators (e.g. total number of prescriptions, number of doses dispensed or number of drugs prescribed). In order to make more direct comparisons between studies, we recalculated some of the delivery error rates. Nevertheless, the studies are heterogeneous. We found only four studies on the effects of these strategies. In the first case, the delivery error rate in a U.S.
hospital increased from 0.19 per cent to 0.07 per cent through the use of a barcode system; In a cost-benefit analysis, the break-even point for return on investment was in the first quarter of the fourth year . In another hospital study, the use of two different dosing methods using a barcode system was investigated: a carousel filling process in which compact forms of common drugs that did not require cold were dispensed in semi-automatic medicine cabinets; and a 2-day filling process in which less frequently used medications were manually stored on shelves and retrieved by hand during the filling stage . The carousel filling process reduced the dosing error rate from 0.25% to 0.018% and the second process reduced it from 0.71% to 0.026%. Two studies examined possible causes of failure to detect and prevent drug interaction problems during childbirth. In the first study, researchers calculated dispensing ratios for 11 adverse drug interactions in 256 Dutch municipal pharmacies; Only one was significantly associated with determinants – the type of medication monitoring system and whether the pharmacy was part of a health centre . The second study was conducted in the United States and examined the relationships between handling 25 potential drug interactions and the operational characteristics of community pharmacies; The risk of dispensing drugs with potential drug interactions was significantly associated with pharmacist workload, overall pharmacy workload, and automated telephone systems for ordering prescriptions . However, dosing errors can also be avoided in a simpler way. We saw a small pharmacy in the north of England carry out a trend analysis to identify the most common drugs involved in adverse events. The information from the analysis led to warnings placed on the edges of the shelf, with the identified stock completely separated from other drugs. Another pharmacy decided to place a physical barrier in front of amitriptyline, which has been identified as one of the drugs most often implicated in false starch defects.
These changes forced staff to review the prescription before choosing the drug. We also saw a pharmacy in the west of England separating individual prescriptions using the clips on a stand next to the labeling computer. This prevented recipes from being mixed, especially for family members, and was a response to an incident where the wrong person`s name had been printed on the label. Table 1 shows the categories of delivery errors [1, 2, 3, 6, 7]. If dispensing errors are considered from the point of view that the quality of all pharmaceutical care activities must be ensured by the pharmacist, this list can be extended by three other categories: failure to detect and correct a prescribing error prior to dispensing; failure to detect a manufacturing defect prior to delivery; and the failure to provide adequate advice to patients to avoid administrative errors.