Community Pharmacy Audit 2013/14

East Anglia Area

Dear Colleague,

This year we are asking all Community Pharmacies to carry out an audit on dispensing and near miss errors that have occurred within the pharmacy.

Patient safety is a high priority within the NHS and evidence shows that reviewing dispensing errors can reduce preventable patient harm from occurring.

Aims

  • To identify and address stages in the dispensing process where errors are most likely to occur
  • To identify and address common types of dispensing and near miss errors that occur
  • To identify and address factors or circumstances that are associated with the occurrence of dispensing and near miss errors
  • To identify appropriate preventative action in response to dispensing and near miss errors

The audit standards

  • All dispensing errors and near miss errors are recorded and reported for a four week period during November 2013
  • The audit will be repeated again early in the next financial year.
  • Two separate logs are kept one for near misses and one for dispensing errors.
  • Robust procedures are in place to ensure that dispensing errors are recorded (already a contractual requirement)
  • All patient safety incidents are reported to the National Reporting and Learning Service at the NPSA (contractual requirement as specified in the approved particulars 2012).
  • Data is reviewed regularly and processes are changed to prevent reoccurrences of errors.

Method

A near miss is defined as a dispensing error that is detected before the patient or patient’s representative is handed the dispensed prescription. A dispensing error is one that is detected after the medication has been given to the patient or their representative.

All dispensing errors and near misses should be recordedon the relevant tally chart. You have been supplied with two tally charts one labelled ‘dispensing error tally log’ and one ‘near miss tally chart log’. Evidence indicates that you will probably collect more near miss incidents than dispensing errors.

Additional copies of the tally chart can be photocopied if required.

For each incident you should mark on the tally sheets

  • Who detected the error
  • At which stage the error was detected
  • The type of error
  • The possible cause of the error
  • The circumstances associated with the error

It is possible that there may be more than one possible cause for the error or associated circumstances so record the relevant ones.

Information on each incident should be recorded by ticking the relevant boxes in the column relating to the incident number. Each tally chart allows you to record 20 incidents. At either the end of the audit or on completion of a sheet the totals for each row should be added up. If more sheets are used at the end of the audit add together the individual sub totals to get the overall total for each row. This information will then allow you to complete the results form by ranking the most commonly identified outcomes. A ranking of 1 indicates this was your most common answer and 2 your second most common answer etc.etc. For example, you may find that the pharmacist detects the most near miss errors and counter assistants detect the least. The ranking for each section should then be put into results form.

A tip in completing the tally charts is to also tick the row that indicates the type of error (labelling, selection or bagging) as well as the specific issue within that error type as this will allow you to easily rank the most common type of error, rather than having to add up all the individual rows within each section.

NB The tally charts are just for you to record your errors. They should not be e-mailed back with the results form. Each pharmacy will collect different volumes of dispensing errors which in part are related to the volume of prescriptions dispensed. All we require are details on the ranking scores. We are interested in the relative frequencies of issues rather than absolute numbers.

On the results form there is an information summary box where you are required to write in your most commonly identified issue for that statement. Finally, you are required to describe what changes you intend to make to reduce your most commonly identified type of near miss and dispensing error from occurring again in the future. These may or may not be the same error source.

Complete the tally charts for a four week period during November 2013 then transfer ranking for each answer to the Audit Results Form and submit by 2nd week of December 2013. The audit will be repeated in 2014/15 in order to assess the impact of changes to practice.

All the sections of the audit results formmust be completed and returned by email to by 16th December 2013.

It is part of your contractual requirement that you must complete this audit.

All data will be assessed and a final report setting out recommendations and actions for improvement will be available later in 2014.

Thank you to the Royal Pharmaceutical Society for the original audit that this is based on.

Yours sincerely

Paul Duell LPN Chair andRuth Kent Primary Care Support TeamEast Anglia Area TeamNHS England CPC1| Capital Park | Fulbourn | Cambridge | CB21 5XE

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