VIEWPOINT

Documenting errors benefits patients, pharmacies

Since the Institute of Medicine's 1999 landmark report on medical errors, there has been more attention paid by the media and the public to medication errors. This focus has led some state boards of pharmacy to more closely examine ways to reduce dispensing errors. Some states, like Florida, California, and Texas, have taken formal steps to help pharmacists reduce these types of errors.

One state's requirements

After some trial and error, Florida's state board of pharmacy is now requiring pharmacies to document and assess dispensing errors. Florida's Continuous Quality Improvement (CQI) program requires pharmacies to keep a log of dispensing errors. It is left up to the pharmacy manager or owner to decide what errors are documented in the log. The log may be viewed only by state board of pharmacy inspectors and is not discoverable in cases of litigation. The board of pharmacy will impose minimal fines if the CQI log is not used or not kept up to date. However, not using the CQI program, or using it improperly, can result in fines up to $5,000.

In Florida, the CQI events need to be reviewed quarterly and a summary report written that includes changes that will be made to reduce errors. Once this is done, the individual error reports may be destroyed.

This program helps pharmacy owners track dispensing errors and allows them to make adjustments in policies or procedures to reduce errors. Some states do not require some form of CQI program relating to dispensing errors, but they may soon. The aim of this editorial is to stress the importance of documenting and assessing dispensing errors and making changes to prevent errors in the future.

Why should a CQI plan for dispensing be implemented? First, it is the only ethical thing to do for patients. Second, starting such a program demonstrates the pharmacy's concern for patient safety. A record of documenting, assessing, and making changes to improve safety shows due care in case of litigation. Third, such a process will help pharmacy owners detect problems they may not be aware of. Last, changes can be made that will prevent similar errors from occurring in the future.

The first step in starting a program is for the pharmacy owner or manager to develop a simple policy and procedure (see below) for dispensing errors. The next step is to have a documentation form to record and assess errors (see sample Quality Improvement Record—QIR).

Sample policy and procedure

Dispensing errors will be immediately documented by the person discovering the error. The pharmacy owner or manager will assess all errors documented at least once a quarter. Changes needed to prevent future errors will be documented and implemented by the pharmacy owner or manager.

The next step is for the pharmacy owner or manager to decide which errors to document. The choices are: (a) all errors, (b) errors in the final product (found in "will call" section or during patient counseling), (c) only errors reaching the patient, or (d) only errors causing patient harm.

Once a dispensing error is discovered, the pharmacist or technician handling the situation should, in a timely manner, complete the QIR to ensure that the information concerning the incident is as accurate as possible and resolve any problems needing immediate attention.

Why CQI works

Data suggest that most errors happen during the processing stage and are caught prior to dispensing. Data also suggest that the number of dispensing errors found in final product in independent pharmacies is quite small. Therefore, the completion of a QIR would not occur often and thus would not require much of the pharmacy staff's time.

This CQI program has the potential of helping users discover the reasons dispensing errors are committed. This will allow pharmacy owners to make needed changes to benefit patients. The benefits of having a quality improvement program for dispensing outweigh any inconvenience in filling out the QIR. In addition, it shows a genuine concern for patient health and safety.

David R. Steele is a fourth-year Pharm.D. candidate, and William N. Kelly, Pharm.D., is a professor of clinical and administrative sciences at Mercer University, Southern School of Pharmacy, Atlanta, Ga.

 

William Kelly. Documenting errors benefits patients, pharmacies. Drug Topics Jan. 26, 2004;148:66.