Safety culture vital for reducing hospital dispensing errors

A new study highlights the importance of hospital pharmacists collecting data and identifying why dispensing errors happen in order to significantly reduce how often they occur.

Pharmacy researchers from Alfred Health in Melbourne conducted a systematic review of 11 studies on interventions that reduce the number of dispensing errors in hospital dispensaries. 

The researchers looked at studies that had a comparative arm so they could evaluate the success of interventions. 

A meta-analysis was performed on the 2,295,539 dispensed medicines in the control group and 2,381,253 in the intervention group.

While the error rate in the intervention group was 0.00043 per 1,000 dispensed items, this represents a potentially large number of prescriptions affected as there are approximately 792,000 prescriptions dispensed each day in Australia.

When interventions were successfully put in place, there was a 53% reduction in the risk of dispensing errors.

The use of trained technicians to perform the final verification of the dispensing process and the implementation of technology, such as barcode scanning, automated dispensing machines or pharmacy carousels, proved to be the most successful interventions, but the key takeaway for pharmacists is the importance of recording errors.

Collecting data

If pharmacists really want to understand why errors occur in their dispensary, there needs to be a targeted process in place, said Susan Poole, lead author of the report and Pharmacy Research Coordinator at Alfred Health.

‘When we were selecting studies to include in our research, we noticed that spontaneous error reporting featured in some of the literature, which tends to result in underreporting,’ Ms Poole told Australian Pharmacist.

‘We chose studies that were conducted using a research methodology, which mostly required an external observer to be present in the dispensary for the purpose of identifying and documenting errors.’

Lauren Burton MPS

Lauren Burton MPS, pharmacist at King Edward Memorial Hospital in Perth and PSA Early Career Pharmacist Board Director, said pharmacists should publish the findings of their quality improvement activities, regardless of practice context, as recording is how funding for safety projects is justified.

‘Hospital executives are often risk and error-focused and seek data to address medicine safety,’ she told AP.

‘When pharmacists are supported with funding, full-time equivalent staff or technology, it is often in response to a reported risk in a hospital environment.’

There also needs to be an appropriate system in place for recording errors to effectively collect this data. 

Ms Burton’s team recently developed an error-recording practice that is in the implementation phase.

‘My colleague created a “near miss” dashboard, which is an anonymous recording of any dispensing errors,’ she said. 

‘It’s not about who did it, but the error that occurred. Having consistent evidence around why these errors are happening will allow us to proactively consider quality improvement activities to ensure they can be prevented.’

To ensure error reporting is more effective, Ms Poole said a ‘no blame’ system should be built into workplace culture.

‘People need to be assured that there won’t be recriminations for reporting errors, because it’s by reporting errors and understanding the problems with systems that we can identify solutions,’ she said. 

The tone of the pharmacist in charge also helps to establish this open and transparent environment.

‘I’m often supervising support staff or interns, and whenever I make an error I share it with them and tell them how I’ve learned from it,’ Ms Burton said.

‘I’m often supervising support staff or interns, and whenever I make an error I share it with them and tell them how I’ve learned from it.’

Lauren Burton mps

‘It’s important to acknowledge that I make mistakes as well, which creates an environment where people feel comfortable to discuss them.’

Acknowledging how different people respond to these situations is another factor to consider.

‘Some people have a really open and comfortable attitude towards being informed about errors, whereas others may appreciate being told about an error in a more private environment,’ Ms Burton said.

‘I’m really fortunate to be in a workplace culture where we inform each other there and then, and we stop and have a think about what happened and how we can support that person to continue doing what they normally do, which is dispense medicines very accurately.’ 

Implementing interventions

After pharmacists have identified why dispensing errors occur, Ms Poole said they need to take a closer look at their dispensing processes.

‘It’s important to clean up the human factors in the dispensing process to ensure those that increase risk are not introduced, and the causes of errors are addressed,’ she said.

Ms Burton agreed that process is key.

‘There should be objective standard operating procedures, and consistent expectations in and around how things are done,’ she said.

‘Standards and guidelines are important for designing standard operating procedures and should inform staff training and education.’ 

Any intervention, technological or otherwise, should be supported by appropriate training, whether that is to operate technology or perform the final verification step in the dispensing process, Ms Poole said.

‘Accreditation is a proactive step that should always be taken,’ Ms Burton said.  

‘In the hospitals I’ve worked in, staff have needed to meet an error-free target, for example 100 dispensings without error, before they are considered accredited to perform that task,’ she said. 

Interventions should also be designed to fit within the hospital’s practices.

‘If a dispensary is implementing a new technology, it’s important to consider if it’s fit for purpose and aligns with workflow,’ Ms Poole said.

‘When solutions have been poorly implemented they are often abandoned due to alert fatigue or if they don’t fit into practices, so there needs to be a lot of careful planning and change management involved.’

Risk assessment is another important step before inputting a new system, Ms Burton said. This entails mapping processes and assessing risk against hospital policy and the standards and guidelines set by national membership organisations, such as PSA.

‘We discovered a risk in the dispensing process of outpatient prescriptions relating to the review of prescriptions for legal, regulatory and clinical requirements after the medicines had been prepared by pharmacy technicians,’ she said.

‘Technicians would do what they could with regards to screening a prescription for legal, Pharmaceutical Benefits Scheme and hospital policy requirements, but the dispensing process was being interrupted when they needed a pharmacist’s clarification, especially for hand-written prescriptions.’ 

Ms Burton’s team identified that the interruption could be leading to dispensing mistakes by assessing dispensary near miss error reporting data. They took a proactive approach to ensure all prescriptions were appropriately screened before the technicians engaged in the dispensing process, which led to a reduction in dispensing errors.

‘We’ve since created a standard operating procedure, which was reviewed before its implementation, along with education for pharmacists and pharmacy technicians about the new system,’ she said.