To name and shame..???

[Pharmanaut]

I have read documentation with near miss reporting schemes which included things as trivial as picking up 250mg amoxicillin instead or 500mg, but realising before putting it down on the bench, and rectifying your own error instantly. I guess it could point to poor shelf layout etc - but if every trivial incident holds up dispensing by 5 mins while you fill in a questionnaire then chaos rules. I am afraid I ignore these schemes now.

That's what I've been told about as well.
To my mind, near miss is one that is picked up on final check.
Ie; one person has said it is 'good to go' and the second person spots the error.

I usually say to the technician/dispenser 'Have another look at that script'.
Don't forget customers can hear our murmurings.

[Erystiva]

The only time that errors made by a dispenser, or checker for that matter, are when an AIMS (Accident & Incident Management System) form is completed after an error has left the pharmacy OR if experiencing recurring errors which should be reported and analysed to determine how the errors can be reduced, either by procedure or training. The only other time that names are involved is when undertaking periods of dispensing or checking accuracy.

We take the person making the error to the side and calmly explain the situation, sometimes making a joke of it if appropriate. Embarrasing or shaming staff that make errors will most likely create a more tense environment which in turn leads to further errors. Do we not have enough paperwork in pharmacy as it is?!?

[bleepholder]

yeah i'm all for minimising paperwork, and mostly can't be bothered filling it in....i just correct the mistake mself, and next time i see the person just mention that they had done something wrong and make a light moment of it!!!

i can't see how making a big song and dance over the situation is going to help anyone....surely it will put the person on even more of an edge, and could slow down their work even further as they become paranoid about making more mistakes....when you got customers waiting for their scripts..not ideal

can you imagine explaining to a customer, soory your script is delayed..my colleague dispensed it wrong so i had to fill in a form documenting the error, then explained it to the person so they could correct it......if i was the customer, i couldn't care less as long as i got my drugs on time and correctly!!

or am i being too much of a slacker in our society of paperwork filling in and error reporting??

[Pharmanaut]

Dispensing?
Thought we went to work to fill forms in, read SOPs, do audits, measurements, balance the CDs, sort scripts into exact price bundles and the rest.

[DavidS]

Embarrassing or shaming staff that make errors will most likely create a more tense environment which in turn leads to further errors.

GPhC and DoH: read the above!

[weeneldo]

I'm a 4th year pharmacy student and I work as a dispenser for a small chain (~8) of pharmacies.

The shop I work in doesn't have any reporting or recording system for errors and I'm pretty sure that none of the shops in the chain do...

[Defblade]

I'm a 4th year pharmacy student and I work as a dispenser for a small chain (~8) of pharmacies.

The shop I work in doesn't have any reporting or recording system for errors and I'm pretty sure that none of the shops in the chain do...

Near miss/error log is a matter of "good practise" rather than legal requirement; not having one could potentially earn the pharmacist a trip to Stat Com but probably wouldn't alone; but it might be raised in the context of a proper error which did lead to a complaint - eg "is this a repeated error in your workplace that could have been picked up before it happened again by using a log?" in either stat com or court.

As a relief, my error log is my diary and goes with me.

[DispenserJosh]

Agreed, that isn't a 'near-miss' but more of a 'nowhere near-miss'. If you yourself have corrected your own error before any subsequent checking takes place, there is absolutely no need to record it!

We review our 'near-miss' and 'dispensing errors' logs at staff meetings, no one is named and shamed. The way I see it is that we all work in our teams, and picking on one person isn't really in the 'team spirit'. If that person has addressed their errors then no harm done!