Dispensing error and near miss recording in Irish community pharmacies

Background: Community pharmacies in the Republic of Ireland are required to have a clear and documented system for the management, review and recording of dispensing errors (DEs) and near misses (NMs). Despite this, only 66% of pharmacies inspected in Ireland maintained error or incident logs in 2016 [1]. DEs causing serious patient harm are infrequent; however, their consequences, including death, can be devastating [2].

Aims: To assess the reporting incidence of DEs and NMs in community pharmacies in the Republic of Ireland, and compliance with national guidelines on their management.

Method: An invitation was sent to all community pharmacies in Ireland (n = 1,688) to participate in an anonymous, proforma, online survey using LimeSurvey. Data collected include general pharmacy information, data on DEs recorded, data on NMs recorded, and data on compliance with recording DEs and NMs over the period 1/1/2019-30/6/2019. A DE was defined as an any error detected after the medication had been given to the patient or their representative. An NMs was defined as any error that was detected before the patient or patient's representative was handed the dispensed prescription.

Results: One hundred and twenty-four (7.3%) full or partial responses were received. Independent pharmacies accounted for 52.2% of respondents. 1/96 (0.7%) of pharmacies reported not recording DEs or NMs, while 2/124 (1.5%) pharmacies did not have a Standard Operating Procedure for recording DEs and NMs. Most pharmacies (83/96, 86.6%) manually recorded their DEs and NMs and approximately 2-in-3 (69/95, 72.6%) pharmacies reported regularly reviewing DEs and NMs. The mean self-reported DE rate was 0.035% while the mean NM rate was 0.135%. The mean ratio of NMs to DEs was 4.7:1. A correlation was observed between the number of items dispensed and the rate of DEs (r = −0.354, p = 0.002).

The top three recorded DEs were incorrect strength (32.1%), incorrect drug (16.7%), and incorrect quantity (13.5%). The top three recorded causes were picking errors (28.0%), similar packaging (16.6%), and similar drug names (14.5%). Pharmacies rated themselves as less compliant in recording NMs (mean: 5.3 on a 10-point scale) than DEs (mean: 7.5/10).

Conclusion: Dispensing errors and near misses in Irish community pharmacies get reported at a similar rate than in other countries. A nationwide reporting program, similar to the ones used in other countries, such as England, Wales, New Zealand, and Sweden, could improve reporting rates, make data analysis easier, and allow pharmacists to learn from their own and others' mistakes, thereby preventing dispensing errors from happening and improving patient outcomes.

REFERENCES

Inspection Findings 2016—Pharmacy Ireland—PSI [Internet]. [cited 2019 Jan 6]. Available from: https://www.thepsi.ie/gns/inspection-enforcement/inspections/Inspection_Findings/InspectionsFindings2016.aspx

Wise J. Government takes steps to reduce annual burden of medication errors in England. BMJ. 2018; 360:k903. Available from: http://www.ncbi.nlm.nih.gov/pubmed/29475859