2.5.5 Handling dispensing errors Flashcards
Professionalism and a culture of candour are vital for patient safety, this is why it is important that…
Pharmacists report, learn, share, act and review instances when there have been dispensing errors or near misses. Pharmacists report various reasons why they find it difficult to report and learn from mistakes.
Whether you are the person who made the error or it was another member of the pharmacy team, once you become aware, you need to…
Promptly take all reasonable steps to let the patient know and to make things right, unless the circumstances mean it is not necessary or appropriate to. Keeping records can also help to justify your decision.
When an error has been made:
1) Take steps to let the patient know promptly
2) Make things right (this may involve contacting the prescriber)
3) Offer an apology
4) Let colleagues involved in the error know.
You can use the steps from the RPS Patient safety professional standards illustrated in Diagram 7.
See Diagram 7: Professional standards for responding to patient safety incidents adapted from Community Pharmacy Patient Safety Group
Community Pharmacy Patient Safety Group Homepage. Available from: pharmacysafety.org.
A legal defence exists to…
The criminal offences relating to inadvertent preparation or dispensing errors for pharmacy professionals working at registered pharmacies.
A legal defence exists to the criminal offences relating to inadvertent preparation or dispensing errors for pharmacy professionals working at registered pharmacies. This includes…
Registered pharmacy professionals working in community pharmacies (The Pharmacy (Preparation and Dispensing Errors – Registered Pharmacies) Order 2018) and registered pharmacy professionals working in hospitals and other pharmacy services (e.g., in prisons and care homes) (The Pharmacy (Preparation and Dispensing Errors – Hospital and Other Pharmacy Services) Order 2022).
The aim of these legal defences are to…
Remove the threat of criminal sanctions for inadvertent preparation and dispensing errors and incentivising an increase in the reporting of dispensing errors.
Further reading
Royal Pharmaceutical Society
Errors and near misses.
www.rpharms.com
Royal Pharmaceutical Society
Patient safety professional standards.
www.rpharms.com
Royal Pharmaceutical Society
Responding to Patient Safety Incidents: Supporting resources.
www.rpharms.com
General Pharmaceutical Council
Keeping patients safe: being open and honest when things go wrong.
www.pharmacyregulation.org
General Pharmaceutical Council
Standards for pharmacy professionals. (See Standard 8) 2017.
www.pharmacyregulation.org
(see MEP Appendix 4)
NHS England
NHS Patient Safety Strategy.
www.england.nhs.uk
Pharmacy (Preparation and Dispensing Errors – Registered Pharmacies) Order 2018.
www.legislation.gov.uk
Pharmacy (Preparation and Dispensing Errors – Hospital and Other Pharmacy Services) Order 2022.
www.legislation.gov.uk
