Now that I am back in the realm of long-term care, it’s apparent that some things have changed significantly since I was last here: automation, prescription-processing software and the role of pharmacists as consultant liaisons to nursing home facilities are just a few. Amongst the items that haven’t changed is the responsibility surrounding incident handling and reporting, and it can be argued that it continues to increase in importance. The recent media focus on pharmacy hasn’t been the most positive.

Between the steps of prescribing, dispensing, and the administration of medication, there are countless ways for errors to occur: transcription, misinterpretation, data entry, assembly, dosing time, dosing frequency, length of therapy, interactions, quantity, packaging and labeling, dropped doses, brand changes, discontinuations, etc (you get the idea). Of course we aim to maintain a similar number of safeguards to prevent such errors, but unfortunately some still manage to squeak through.

As we become more advanced with our packaging systems and software, there has been a steady shift in the quality and quantity of medication errors requiring a response and an action plan. Here are some observations and some points for consideration:

1) Reporting rates have increased – Both at a facility level and the dispensary level, we are seeing more reports flowing through. There has been a conscious change through regulatory bodies to report any and all perception of error, regardless of who may interpret the potential risk (administrator, pharmacist, assistant, RN, LPN, family member, etc).

2) Errors are more easily identifiable – If drug administration moves from a multi-dose to a unit-dose packaging format, it becomes apparent if single doses were given or not. If doses were provided from a vial, the risk of double-dosing or under-dosing is higher, but not necessarily identified until a later date (if at all). The emergence of electronic medication administration records (eMAR) has added a new layer of error potential as well; if stop dates aren’t entered properly by pharmacy staff, it will prompt a dose to be given after a course is complete and no inventory remains.

3) The vast majority are of the ‘near-miss’ variety – This tells me that the quality assurance measures we employ are working. Problems are identified prior to administration of medication, so there is virtually no potential for patient harm, yet we may still craft action plans to prevent recurrence.

4) The severity of actual medication incidents is declining – This is a personal observation in that I don’t have any comparative evidence to recite. We used to see errors within drug classes with similar strengths and directions (i.e. paroxetine vs. fluoxetine, metoprolol vs. atenolol), or look-alike drugs that end up in the same bottles (i.e. Synthroid 50ug/domperidone 10mg, lorazepam 1mg/gliclazide MR 30mg, Tylenol #3/Metformin 500mg, etc). These types of errors are devastating for everyone involved. Our prescription-processing systems and packaging automation go a long way to prevent wrong product or strength dispensing. However, if a broken tablet was found in a vial, it may not be recorded as an incident, but if it’s in a unit-dose package, that specific dose is incorrect and should be recorded as such.

5) Raw numbers alone do not tell the whole story – Nobody likes to have incidents of any kind, but we need to report them to learn about gaps in our training and our service that we genuinely want to address. Without any context, an incident rate may be considered high or low, but we need to dive deeper into the severity of errors being reported and the steps involved in the breakdown. One example I have was from a number of years ago that was recounted by a pharmacy manager friend of mine. A batch of unit-dose packaging was run with an incorrect start date. In this case, the first medication pouch was due to start on Sept 23 when it should have been Sept 24. Upon delivery, nursing staff would have received a duplicate day of medications and this was identified right away. The pharmacy was notified and in response, corrected an administrative error where two staff members failed to properly sign-off on checking the dates. As this particular batch had twelve people, it was reported as twelve separate errors. I concede that from a facility side, the near-miss could have potentially affected twelve people. From a quality assurance perspective, there was one procedural error, and therefore one action plan to execute. The quarterly service report nevertheless looked quite poor, and pharmacy staff were discouraged.

In closing, the last thing anyone wants is a culture of fear. Error reporting in any setting should be about transparency and working together for the benefits of our mutual patients. We learn and adapt our programs to properly address shortcomings in a timely manner, with penalties reserved for a failure to take steps to fix whatever may be flawed, not for the reporting itself.

We are proud to strive for a world where no mistakes are made and therapies result in optimal outcomes. Till then, we will continue to support each other to follow-up errors and use a team-approach to discuss remedies.

After all, there is only one problem with being perfect; you never learn know how to fix anything.

Disclaimer: The views and opinions expressed in this article are those of the author(s) and do not necessarily reflect the official policy or position of any agency, employer or affiliation.