Drug Topics - May 26, 2008 - (Page 3) 3 REDUCING YOUR RISK Ken Baker, B.S. Pharm., J.D. Medication errors: Why record near misses? S everal states have passed or are considering regulations requiring pharmacies to institute quality assurance programs designed to reduce medication errors. As a part of such rules, the boards of pharmacy usually include a requirement that the pharmacy’s quality assurance system include a method of recording and analyzing medication errors. By studying medication errors, the boards say, a pharmacy can learn from past mistakes and continuously improve their system, reducing the likelihood of future errors. Such board of pharmacy requirements are wellmeaning, but most miss the mark. In requiring only that the pharmacies record errors, they miss the most valuable aspects of a continuous quality improvement (CQI) program. Errors are only the tip of the proverbial iceberg. The information that needs to be recorded and analyzed is not just the errors that get all the way through the system to the patient, but the near-misses that the system caught. The lessons of what worked are just as useful as the lessons of what failed. In 2000, the Institute of Medicine issued its now famous report entitled To Err is Human, in which the IOM studied the wider problem of preventable adverse medical events. A critical part of the IOM’s recommendation was to study errors and near-misses. Conceptually, the IOM report says, “the purposes [of an error reporting system and a near-miss reporting system] are not incompatible, but, in reality, they can prove difficult to satisfy simultaneously.” Some states are now studying regulations that would encourage or even mandate reporting of errors and near-misses, but specifically for the purpose of CQI. In these states, the board has access only to the cumulative information as proof that the pharmacy is collecting and analyzing data. These boards do not have access to the pharmacy’s specific error information. Therefore any fear that the board will use information entered to institute disciplinary proceedings is eliminated. The board may still require error reports, but not as part of a quality assurance program. Oddly, some pharmacies accept and even encourage the mandatory error reporting systems even though the board is given access to and use of the information. At the same time, these pharmacies object to a requirement of reporting near-misses, even though this information is non-punitive in nature and gives the best method of learning where the vulnerability in the system may be located and fixed before an error occurs. Pharmacies object to taking the time to record and analyze every near-miss. Pharmacists who actually record every near-miss are amused by the reaction. With a good system, it takes approximately 30 seconds to record a near-miss. Since a pharmacy with a CQI program will have less than one QRE or quality-related event (near-miss + error) for every 200 prescriptions, it would be a very busy pharmacy that would spend more than an extra five minutes a day recording this information. Recording the information is, of course, only a part of the process of learning. The second step is using the information. If we had to study and analyze each individual near-miss and error, the task may indeed be time consuming. That is not, however, how this volume of information is best used. The value is in statistical information. Selectively use one piece of information each month. As an example, using a system that enabled one pharmacy to capture all errors and near-misses and to then produce a pie chart of the results yielded the finding that 10% of all of the mistakes (some errors, some nearmisses) made in one 30-day period was in typing the directions incorrectly during computer entry. Another pharmacy found that 60% of its mistakes and 30% of its errors occurred during computer entry. Using this type of statistical information allows a pharmacy to proactively avert such errors in the future. The information is only valuable, however, if it is recorded routinely by everyone in the pharmacy. That will only happen if fear of recording what happened is eliminated. References are available upon request. This article does not constitute legal or consultative risk management advice. You should not rely on the information here or in any similar article for a plan of quality or for legal matters. Consult a risk management consultant or an attorney. THE AUTHOR practices law as an attorney, of counsel, with the Arizona law firm of Renaud Cook Drury Mesaros, PA. He also consults in the areas of pharmacy error reduction and risk management. For questions or citation and footnotes, the author can be reached at ken@kenbakerconsulting.com.
Table of Contents Feed for the Digital Edition of Drug Topics - May 26, 2008 Drug Topics - May 26, 2008 Contents Medication Errors: Why Record Near Misses? Pharmacist Finds Joy in Art Upon His Retirement New Products Latest News Roundup Drug Topics - May 26, 2008 Drug Topics - May 26, 2008 - Contents (Page 1) Drug Topics - May 26, 2008 - Contents (Page 2) Drug Topics - May 26, 2008 - Medication Errors: Why Record Near Misses? (Page 3) Drug Topics - May 26, 2008 - Pharmacist Finds Joy in Art Upon His Retirement (Page 4) Drug Topics - May 26, 2008 - New Products (Page 5) Drug Topics - May 26, 2008 - Latest News Roundup (Page 6)
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