Boots tackles causes of dispensing errors
Boots The Chemists has launched an initiative aiming
to analyse and eliminate risks from dispensing. The company says that
the new dispensing incident management handbook provides pharmacists with
a process to analyse the contributory factors to errors and to prevent
future ones occurring. It also helps pharmacists meet clinical governance
requirements by forming the basis of an audit trail to demonstrate how
risks are being managed.
Steve Eastham, head of clinical governance, Boots,
says: “The aim of the handbook is to manage risk, whether these are incidents
that reach patients or are near misses. We need to learn from system failures,
and that can only be achieved by encouraging reporting of all circumstances,
and through a just and fair approach in an atmosphere of trust.”
The initiative recognises that there are many contributing
factors to errors and that the system is not designed to attribute blame
but rather to identify the cause of the system failure and prevent it
happening again.
Factors contributing to each incident are to be
identified and classified as task related (part of the process of dispensing),
workplace related, team related or person related (an individual’s role).
Near misses are to be recorded within the dispensary. Errors reaching
the patient are reported in a dispensing incident action form and sent
to the Boots head office. Reviews are to be conducted after every six
near misses or errors. Information will be collated and disseminated throughout
the Boots organisation by regional professional development managers.
Amanda Lloyd, a pharmacist at the Nottingham store
where the initiative was piloted says: “The handbook has been really helpful
in pinpointing causes for near misses. We now have a weekly review as
a team to identify small changes that can have a big impact on the quality
of our dispensing.”
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