3 causes of medicines to be wrongly dispensed
- drug names are similar and so are mixed up
- bagging errors
- looking at previous medical history
3 factors that cause prescribing errors
- improper training
- lacks of drug knowledge and training
- lack of knowledge of the risk
- communication
- workload
What are ways in which risk of errors is reduced
SOPs:
- accuracy checking using 2 people before supplying a med
- storage of meds, making similar drugs distinguishable
Reporting:
- error logging and learning from errors
- investigating reasons behind the mistakes
Culture
- creating a culture that ensures carefulness
What do you do when you in the event a dispensing error is made is made
- let the patient now promptly
- make things right and inform the prescriber
- apologise
- let colleagues involved know
The error needs to be reported and what went wrong is evaluated and the error is learned from.
What is the RPS error reporting guidelines
- be open and honest
- report
- learn
- share
- act
- review
Under what circumstances can legal defence be used to prevent criminalisation when dispensing errors occur
Only if:
- dispensed in a registered pharmacy
- AND a registered responsible pharmacist was supervising
- AND dispensed against a prescription from a prescriber or a PGD
- ANDA the patient is promptly notified once the error has been identified.
What happens when an error is reported to the GPhC
They review the errors against a set of criteria and a decision will be made whether to pass the investigation onto the FTP committee or the investigation committee.
When is an investigation referred to the investigation committee
- When the persons conduct presents a rick to patients/ public safety
- undermines confidence in pharmacy professions
- there has been persistent failure to meet the standards
- the honesty and confidence in the pharmacy profession is damaged
