Reducing dispensing errors in CGH Pharmacy

Quality Improvement Poster Download

Background & Problems

What is a dispensing error?

Dispensing Error: “Any deviation from the prescription order, whether that be drug, label or contents”. “Prevented” Error or Near Miss: any dispensing error picked up at final accuracy check BEFORE items leave pharmacy dept. “Unprevented” Error: error which gets missed by final accuracy check and leaves the pharmacy dept.

• High proportion of items with errors puts pressure on the final accuracy checkers
• Increased risk errors will get through final check and get to the patient
• Disrupts dispensing process and reduces efficiency

Aim

Reduce the average prevented dispensing error rate to < 4% by 1st May 2016.

Method

Main outcome measure:

• Prevented Error/Near Miss rate (%)

Balancing measures:

• Time taken to dispense TTOs •Staff feedback (qualitative)

Results

• Have dispensing staff re-do dispensing accuracy (200 items, no mistakes)
• Started off with first staff member starting on the 25th Jan
• Since then 3 more members of staff have started
• Moved trolleys around (8th Feb)
• Review shortcode list and display in place where dispensers can easily use them (29th Feb)

Implications

• How to do QI project
• Need to improve staff engagement
• Reasons for improvements “slipping”?
  • More process-related than environmental?
  • Need to be willing to invest more in project?
  • Other changes? i.e. staff shortages, use of locums, bank holidays
• Other measures?

Next Steps

• Further analyse current data
• Restart project ~ Sept 2016
• Major process re-design – incorporate LEAN principles
• Consider implementing barcode scanning/prescription tracking system to reduce phone calls (recent work in GRH)
• Consider more drastic work area changes (resources permitting).