Inspectors' Advice on Medication Error Management

Information and Resources

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• Who is responsible for medication error management?

  
  

  The management of medication errors is the responsibility of everyone in the pharmacy team, but in particular the supervising and superintendent pharmacist(s). All staff should be trained to identify and manage medication errors and near misses, including the recording and reporting of these errors to the pharmacist on duty. The supervising and /or the superintendent pharmacist must be made aware of all medication errors. Further guidance in respect of the responsibilities for error management and error minimisation is outlined under the superintendent pharmacist’s role and the supervising pharmacist’s role.

  
  

  All members of the pharmacy team must be aware of the lessons learnt, corrective actions and preventative actions arising from the management of medication errors and near misses in the pharmacy. All members of the pharmacy team should accept that errors may occur, but the correct response to and management of these errors is essential to ensure patient safety. It is important that there is open communication about errors and that the root causes of errors are addressed to prevent reoccurrence.

• What is a Corrective Action?

  
  

  This is an action taken to ensure that any impact to the patient is minimised. If an error has reached the patient, the response by the pharmacist to the error must be prompt and address the needs of the patient. Appropriate corrective actions, which address the patient need, must be identified by the pharmacist, in conjunction with the supervising pharmacist and other medical personnel, if appropriate, using their professional judgement. Corrective actions may include, for example, referral of the patient to their GP or hospital or replacing incorrect medicines.

• What is a Preventative Action?

  
  

  This is an action taken to prevent the reoccurrence of this type of error. The procedures and practices in the pharmacy which may have contributed to or caused the error should be reviewed by the pharmacist, with the supervising pharmacist. Preventative actions may include, for example, separating different strengths of the same medication on shelves where a picking error has occurred, or re-training staff on the relevant Standard Operating Procedures (SOPs).

• What Records do I need to keep?

  
  

  A record of all medication errors that have occurred must be maintained at the pharmacy. The record should include details of the medication error, when the error occurred, how it was discovered, how and why it occurred. The corrective actions taken to manage the error and the patient’s care should be recorded. In addition, you should make a record of any preventative actions implemented to ensure that the error does not happen again. It is very important to record full details of interactions with the patient and other healthcare professionals. Please record any other information that you consider appropriate.

  
  

  Where a near miss has occurred, a log containing details of near misses should also be kept and reviewed regularly.

• Why do I need to keep a record of Near Misses?

  
  

  A near miss is a medication error that does not reach the patient. Typically, near misses are identified during the final pharmacist check of prescription medicines prior to supply. The identification and recording of near misses allows for these near misses to be reviewed and actions taken for any potential errors to be avoided in the future.

• Where can I find templates of an error log and a near miss log?

  
  

  Pharmacies may already have their own templates for recording medication errors and near misses.

  
  

  If not, to help pharmacists to manage medication errors and near misses, the PSI inspectors have developed two templates:

  • medication error report form
  • medication near miss log