reporting of dispensing errors and fear of litigation

[Zoggite]

At least God doesn't think he's a doctor!

[Pari]

Dear Zoggite
In the holey Koran there is a verse which means that the heal is in the God's hans (he is the Healer), so I think according to some religions the God himself is the Doctor!

[admin]

Dear All

Ignore the comments made by the guest. I know who the guy is and he's a nasty piece of work. He's a pharmacist not a doctor.

He's determined to see this forum flop, so we'll just ignore him ok?

I tnink it's just jealously because he hasn't got the brains to start a forum!

:shock:

[Jeff]

Getting back on topic,
Error, near miss and intervention reporting is important.
We can and do learn from our own mistakes - but reporting gives us the ability to learn from each others.
Most employee pharmacists have little control over which generic we get yet we must have all had near misses with he old APS packs.
Errors are multifactorial - we canot address all the factors unless we record them.

Jeff

[Linnear]

Getting back on topic,
Error, near miss and intervention reporting is important.
We can and do learn from our own mistakes - but reporting gives us the ability to learn from each others.
Most employee pharmacists have little control over which generic we get yet we must have all had near misses with he old APS packs.
Errors are multifactorial - we canot address all the factors unless we record them.

Jeff

Hi Jeff I agree with what you say but why do all the forms I've seen have spaces for names. Surely it doesn't matter who made the mistake and surely if you fill out your own name you are admitting a criminal offence.

[Jeff]

Hi Jeff I agree with what you say but why do all the forms I've seen have spaces for names. Surely it doesn't matter who made the mistake and surely if you fill out your own name you are admitting a criminal offence.

Near misses aren't criminal offences,
Mistakes we admit to, and try to correct anyway (I hope),
and as for interventions - there is a need (at least within the UK) to demonstrate our usefulness and the need for pharmacists.

Jeff

[Linnear]

Hi Jeff I agree with what you say but why do all the forms I've seen have spaces for names. Surely it doesn't matter who made the mistake and surely if you fill out your own name you are admitting a criminal offence.

Near misses aren't criminal offences,
Mistakes we admit to, and try to correct anyway (I hope),
and as for interventions - there is a need (at least within the UK) to demonstrate our usefulness and the need for pharmacists.

Jeff

Hi.

I do see your point but I still do not see that names need to be placed on these lists.

As for interventions I see them as the same as the new CPD regs. There is no pharmacist that works who does not do at least a dozen interventions and CPD applicable information phone calls a week. Maybe we do need to show our worth but all it amounts to in the end is more paperwork

[Zoggite]

Why are they called "near misses", anyway?
Surely "near hits" is more accurate; I go by the principle that "it's not a dispensing error until it's left the pharmacy"; if it's picked up on before, it just shows that our failsafe mechanisms are working!

[Jeff]

Why are they called "near misses", anyway?
Surely "near hits" is more accurate; I go by the principle that "it's not a dispensing error until it's left the pharmacy"; if it's picked up on before, it just shows that our failsafe mechanisms are working!

Someone unpacking the oder has put a packet of 28 APS metoprolol 50 on the 28 APS metformin 500 pile - and the metoprolol appears on the dispensary bench in the middle of a dozen packets of metformin.

Sources of error could include sourcing both metformin and metoprolol from APS, using pack sizes of 28 for both, the arrangement of stock in the dispensary, as well as telling someone to be more careful when puttiing away the orders.

Why wait until you've given them out before addressing the potential for error?

Jeff

[Jeff]

As for interventions I see them as the same as the new CPD regs.

Friday I recieved unsigned scripts for 29 items from the addiction unit and four signed scripts for methadone 35ml daily supervised mitte 0 (zero) ml

Do I just get my scripts sorted and call it a day?

I'm logging it as a critical incident.

Jeff