The following is an example of a near miss that took place in a community pharmacy setting. The analysis of the near miss is presented to highlight the learnings that can come from such cases along with possible quality improvements that a pharmacy team may implement into their practice to prevent future recurrence and patient harm.
The College’s expectations under the mandatory Assurance and Improvement in Medication Safety (AIMS) Program are described in the second section titled “Applying the AIMS Program to This Near Miss”. The AIMS standards are outlined and applied to the incident to highlight how pharmacy staff can incorporate continuous quality improvement into their pharmacy setting using this worked example.
By Ian Stewart R.Ph, B.Sc.Phm.
Pharmacists and pharmacy technicians must be aware that pediatric doses can be stated in one of two ways: either as mg/kg/dose or mg/kg/day. This lack of standardization coupled with the vulnerability of the pediatric population makes it essential that pharmacy professionals use extra care when assessing and confirming indications and doses for pediatric prescriptions.
Amoxicillin 250mg/5ml Suspension
Sig: 80mg/kg BID for 7 days.
The above preprinted prescription for a fifteen-month old child was taken to a local community pharmacy.
The pharmacy assistant entering the prescription into the computer input the dosage as 80mg/kg/dose.
The direction for use was therefore entered as 16mls (800mg) twice daily for seven days.
Upon checking the prescription, the pharmacist confirmed the indication for use as acute otitis media which was printed on the prescription.
An appropriate reference was consulted and the recommended dose for otitis media was confirmed to be 80mg/kg/day, not per dose as entered.
The directions for use were therefore corrected to 8mls twice daily for seven days.
POSSIBLE CONTRIBUTING FACTORS:
- The computer generated prescription provided the incorrect dose (80mg/kg)
- The pharmacy assistant entering the prescription did not clarify the dosing with the pharmacist which led to the entry of the prescription as written (i.e. 800mg BID x 7 days)
- Instruct staff to always collect and record the patient’s age, weight and the indication for use when accepting prescriptions for pediatric patients.
- Confirm whether the weight provided is in pounds or kilograms. An estimate of the child’s weight based on their age may be used to double check.
- The child’s age, weight, the indication for use and recommended dosage regimen should always be used to ensure that the appropriate drug and dosage are being dispensed.
- Double check all pediatric doses for appropriateness as these patients are at an increased risk of experiencing harm.
- Be aware of the potential for error due to the failure to convert pounds to kilograms, as the patient’s weight is usually provided in pounds while dosages are usually stated per kilogram.
- Wherever possible, a second individual should independently complete the calculation without prior knowledge of the results of the first calculation.
- Though computer generated prescriptions can minimize medication errors due to illegible handwriting, be aware of the potential for incorrect pediatric dosages.
- Always take the necessary steps to clarify any ambiguous aspect of a prescription.
- Educate the prescriber of the potential for error and recommend a change in printing format if possible. Suggest that the software vendor be contacted for assistance.
Please continue to send reports of medication errors in confidence to Ian Stewart at: email@example.com. Sharing your experience can prevent similar occurrences at other practice sites. Please ensure that all identifying information (e.g. patient name, pharmacy name, healthcare provider name, etc.) are removed before submitting.
APPLYING THE AIMS PROGRAM TO THIS NEAR MISS
Under the AIMS Program, pharmacy professionals must anonymously:
- Record incidents and near misses to the AIMS Pharmapod platform in a timely manner,
- Analyze the incident or near miss to identify possible contributing factors and the root cause,
- Document plans to minimize the likelihood of the incident recurring by generating learning points and action items for implementation by the pharmacy team,
- Share learnings from the near miss or medication incident with all pharmacy staff
All of the above elements are equally important in helping to reduce the risk of a medication incident or near miss from reoccurring in the future and leading to patient harm. Details on each of the above elements and the overall AIMS Program expectations can be found on the AIMS webpage and within the Supplemental Standards of Practice: Mandatory Standardized AIMS Program in Ontario Pharmacies.
The near miss and associated details must be anonymously recorded in the AIMS platform.
Recording the incident helps the pharmacy to monitor trends and devise actions plans. It also contributes to aggregate data that is used to identify trends and disseminate learnings for pharmacy professionals across the province with the goal of preventing similar incidents in the future.
Application of Standard
When the near miss is identified, it is expected that the details are recorded in the AIMS Pharmapod platform as soon as possible. The incident form guides users through a variety of questions including, “What happened?” (i.e. incident type). In this case the appropriate selection would be “incorrect concentration or strength”.
The analysis of the near miss takes place in a timely manner to identify contributing factors.
This allows for the determination of an action plan to implement appropriate steps to minimize the likelihood of recurrence of the incident in the future.
Application of Standard
The CQI tools in the AIMS Pharmapod Platform (i.e. risk matrix and 5 whys tool) can be used to assist with incident analysis and will appear once the near miss is entered into the platform. The whole pharmacy team, particularly anyone who may have had a part in the near miss, should be involved in the analysis.
Documentation of the following elements is expected: action plans and quality improvements implemented.
Once the incident has been analyzed it is expected that pharmacy staff document continuous quality improvement plans, such as specific actions that are to be taken in response to the near miss.
Application of Standard
The recommendations outlined in Ian Stewart’s article are examples of action plan items to be documented in the AIMS Pharmapod platform either under “Learning Points” or “Actions.” Once documented, these actions or learning points are visible to all staff who have access to the platform which facilitates implementation and follow-up.
Communicate near misses to all staff, encourage open dialogue on medication safety, monitor CQI plans and improvements implemented.
Application of Standard
In addition to discussing the importance of collecting specific information for pediatric prescriptions, an agreed upon process should be used to implement the CQI recommendations. For example, a process to ensure that prescription indication and patient weight is collected and recorded on each pediatric prescription received.
AIMS PROGRAM CONTACT INFORMATION
|Account activation and DM changes
|Technical or log-in issues
|AIMS program standards and expectations
|Website or AIMS@ocpinfo.com
|Pharmacy Staff with log-in issues
|The Designated Manager