As prescribers and dispensers of medicines, pharmacists have a vital role to play in ensuring the safe use of medicines. When something goes wrong, it can have a significant impact on patients and/or lead to a complaint. 

Building on PDL’s recent practice alert, Claire Antrobus MPS, PSA’s Manager – Practice Support, explains how pharmacists should approach the incident reporting process.

All incidents should be reported

PSA’s Professional Practice Standards (PPS) defines an ‘incident’ as ‘An event or circumstance where an error has been made, and a person or patient becomes aware of the error, irrespective of any outcome’. 

This could include a dispensing error, an error with advice or a professional service.

Every incident should be reported, no matter how significant the outcome could be, said Ms Antrobus.

‘Some examples of reporting incidents include reporting a patient’s adverse reaction to a medicine to the Therapeutic Goods Administration, or reporting dispensing errors to management and your professional indemnity insurer,’ she said.

Near misses – defined by the PPS as ‘An event that could have resulted in unwanted consequences, but did not because either by chance or through timely intervention the event did not reach the patient’ – should also be documented.

‘Even if the patient is not aware of the event, it should still be recorded as part of the quality improvement systems for the pharmacist and the pharmacy,’ she said.

The importance of documentation

It can be ‘incredibly stressful’ to have a complaint made against you, and recalling the exact circumstances of the incident can be challenging, said Ms Antrobus. 

‘Documenting the incident at the time it occurs ensures the details are fresh in your mind,’ she added. 

Even if an incident seems trivial, it might not be unimportant to the patient. 

‘Having a record of the incident will assist your professional indemnity insurer to help you if a complaint is made,’ Ms Antrobus said. 

Good record-keeping systems of incidents and near misses is also a great way to identify if there are any trends that can be prevented. 

‘This can help you and/or the pharmacy to review processes to minimise the risk of the incidents or near misses happening again,’ she said.

Keeping detailed records

When writing an incident report, it’s important to keep it professional and stick to the facts without assigning blame. 

‘Make a record according to the pharmacy procedures, for example in the dispensing software or incident register,’ said Ms Antrobus. 

‘You should also keep your own personal record and report the incident according to your professional indemnity insurance process.’ 

Record all the details of what happened, which may include:

• time
• date
• patient
• details of the incident
• any contributing factors
• what was done to resolve the incident/near miss
• any follow-up actions. 

The post-incident process

Incidents and near misses offer an opportunity to review processes to make sure they don’t recur. 

‘Reviewing the incident may identify contributing factors that led to the event that can be addressed, for example similar names/packaging of medicines placed close together in the dispensary,’ said Ms Antrobus.

Pharmacists should also consider any gaps in knowledge that may have led to the incident and undertake relevant CPD activities to fill them. 

But a supportive, open approach – with a ‘no-blame’ or ‘non-punitive’ culture – is key to supporting staff members to report incidents and near misses. 

‘No one intends to make an error. The important thing is to try to make sure the same thing doesn’t happen again,’ she said. ‘The Pharmacists’ Support Service is available if anyone is struggling after an incident.’

PSA support services that can help

PSA has an extensive range of professional standards, practice guidelines and continuing professional development that can help pharmacists be the best they can be.

‘Keeping up to date with best practice and new developments is a great way to prevent incidents,’ said Ms Antrobus. ‘PSA also has a Pharmacist-to-Pharmacist Advice Line to help you ask any curly questions you might have.’