Home' Australian Pharmacist : October 2011 Contents Vol.30–October#10,2011
By Romano Fois
As an intern pharmacist many years
ago I was seriously shaken by my first
dispensing error. The incident involved
selecting and using an incorrect
intravenous infusion solution for the
delivery of an antibiotic. While this
did reach the patient, we both were
fortunate that the infusion solution
selected was innocuous and not
incompatible with the antibiotic. On
that same day, and on every day
since, many other incidents involving
pharmacists, doctors, nurses,
dentists and other health workers
have occurred in Australia and around
the world in hospitals and in the
community where patients have been
unintentionally harmed by the health
systems that exist for their care.
I was alerted to my error when it was
detected by a nurse on the ward.
I recall being directed to be more
careful in future and the incident was
never discussed again. I also recall
many days of reflection on how I could
have made the error, sleeping poorly
and being ultra-vigilant in everything
I did. I needed to become flawless in
how I practiced.
Now, I have come to realise that a
number of factors contributed to the
incident I was involved in on that day,
that no human is flawless and that
an opportunity was lost for sharing
what happened with my colleagues,
for collective learning to occur and for
safer work systems to be developed.
Over the years, I have detected
and prevented many potential
incidents from reaching patients.
Many incidents in primary care share
common characteristics in their origins
but opportunities have not existed
in Australia to address their causes
through sharing what is learnt when
they are detected.
Around the world, health systems are
turning to other industries to learn
how to improve their safety records.
Currently, rates of harm from health
care are significantly higher than
what is seen in other, once high-risk,
industries such as aviation. These
industries recognise human fallibility
and design their systems to prevent
or mitigate the failings of humans.
They also recognise that latent factors
in work conditions, environments,
processes and tools can set up people
and systems to fail.
These industries have a strong safety
culture; one that avoids blaming
individuals when things go wrong
but rather celebrate the opportunity
to learn from errors and to redesign
systems so that similar incidents can
be prevented in the future.
A central strategy to improving safety
in many environments involves the
use of incident reporting programs.
For healthcare systems these
programs allow individuals to report
incidents where patients have (or
could have) been harmed from
unintended actions or omissions.
The analysis of these incidents and
the factors that contribute to them
often reveal latent systemic failures or
traps that can be addressed through
designing new ways of delivering care.
Medicines feature prominently
in many patient-safety incidents.
Community pharmacists are well
placed to identify problems with
the prescribing, dispensing, access,
use or monitoring of medicines.
Pharmacists, through their interactions
with patients and other primary-
care health workers are also able to
identify some of the factors that may
contribute to these problems.
With this in mind, my colleagues
Professor Andrew McLachlan,
Associate Professor Timothy Chen,
a number of research students and
I have been developing systems for
community pharmacists to report
medication-safety incidents that are
encountered in daily practice where
patients have been or could have been
In November we are inviting you
help us to identify and address some
of the factors that pose a risk to
patient safety in Australia through
participating in National Medication
Safety Week. To participate, we
ask you to report anonymously any
medication-safety incidents that you
encounter from 7 to 13 November.
Research student and pharmacist,
Rachel George, will be coordinating
and conducting this initiative. With
our assistance, Rachel will classify
and analyse the incident reports using
a recognised patient-safety analysis
system. From this analysis we will
be able to categorise the types of
medication use problems that are
occurring in the Australian community-
care environment, understand the
contributing factors and develop
specific strategies to improve patient
safety. For more information about
this initiative and to participate, please
Romano Fois is a Lecturer at the Faculty of
Pharmacy, University of Sydney.
7-13th NOVEMBER 2011
Please visit www.australianpharmsafety.org
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