Advice on Medication Error Management

Although pharmacists try very hard to avoid medication errors, sometimes they occur in pharmacy practice. The way a pharmacist handles a medication error often has a direct effect on the patient, and affects the likelihood of another medication error occurring at the pharmacy.

At all routine pharmacy inspections, PSI inspectors review medication error management records in place at the pharmacy. This review includes checking that the pharmacy has policies and procedures to assist all members of staff in dealing with, and learning from, medication errors, as well as that records of medication errors and near misses are maintained at the pharmacy.

To assist pharmacists and other members of the pharmacy team, our inspectors have prepared some frequently asked questions and answers on this important subject.

What is Medication Error Management?

Medication error management is a key part of the pharmacy’s quality management system. A pharmacy must have a clear, documented system for the management, continuous review and recording of medication errors and near misses. The purpose of error management is to:

  • identify mistakes
  • make sure the appropriate action is taken to safeguard the health of the patient where a mistake has taken place
  • ensure accurate records are maintained
  • learn from mistakes, and
  • minimise the risk of future mistakes.

The maintenance and review of error and near miss logs as part of an error management system will facilitate the identification of any patterns or repeated errors, help identify learning needs and the consequent re-training of staff, and contribute to the continuous review of the policies and procedures of the pharmacy.

Template documents that can be used for the recording of medication errors and near-miss incidents are provided below.

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. 

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.

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.

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).

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.

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.