ISMP Canada: Pharmacies caught 700+ near misses in one month alone. Here’s what they taught us

In April 2023, community pharmacies reported 721 near-misses—mistakes that could have caused harm but were caught before they did—to the Institute for Safe Medication Practices Canada (ISMPC). They included prescriptions for drugs patients were allergic to, sound-alike medications being prescribed instead of the correct ones, and a pharmacy staffer putting two patients’ prescriptions in the same bag. ISMPC analyzes those near-misses and published its key takeaways in a new bulletin, “Good Catches in Community Pharmacies: A Multi-Incident Analysis.”The most common near misses were having the wrong dose or frequency (147), incorrect quantity (124), the wrong drugs (110), the wrong prescriber on the label (87), and an incorrect strength or concentration (79). Pharmacists caught the most errors—82%—and other pharmacy team members caught 15%. (The prescriber, patient or caregiver caught the last 3%.) Read: The five most common e-prescribing errors: ISMP CanadaIn several cases, a second pharmacist found a mistake. Having a second pharmacist available supports medication safety, ISMPC said, though it also acknowledged that’s not always possible. In those cases, pharmacists working alone can delay their self-check process or arrange for the pharmacist on the next shift to double-check for things like high-alert medications. Most (52%) of near-misses were found in the prescription verification during dispensing—either when verifying the system’s order entry against the original prescription or checking clinical appropriateness. In one, a prescriber prescribed Amlodipine for a patient, and a pharmacist noticed that the medication had been discontinued six months ago. In another, a pharmacy saw that a prescription was for an antibiotic to which the patient had an allergy. Read: Hospital-acquired hyponatremia risks and solutions: ISMP CanadaTo prevent problems through these checks, ISMPC says prescribers should include the indication and the patient’s weight in their prescriptions and keep patient records updated with information such as when medications are discontinued. It also encourages pharmacy teams to confirm the medication's indication and document it, obtain the patients’ weight if the medication dose is weight-based, and keep their own patient records current with up-to-date information about things like non-prescription medication and allergies. It also recommends pharmacies use bar codes to confirm medications, create designated work areas for high-risk activities, and have a pop-up alert or look-alike and sound-alike medication drug files. Another 18% of the errors were found during the product check. Another 7% of misses were found during prescription preparation, and 9% at pickup. Asking for a second identifier—like date of birth—can help catch mistakes at pickup, as can opening the vial and showing its contents to the patient.Read: Eight ways healthcare professionals should create safe spaces for patients: ISMP CanadaIn one example, prescriptions for two patients were put together in one bag. A pharmacy assistant checked the vials and found the mistake before giving them to the patient. Emphasizing the importance of pharmacy support staff in preventing medication errors during orientation can help reinforce this role, ISMPC says. Prescription intake (3%), patient counselling (3%) and “other” (8%) rounded out the list. A counselling example was highlighted where a patient who should have been prescribed ciprofloxacin eye drops but was prescribed ciprofloxacin ear drops. A pharmacist found the error when counselling the patient, who shared that the medication was to treat an eye infection. Patient consultations like this should be the final check in the process, ISMPC advises. Prescribers should also give patients a copy of their new prescriptions so they can use them to double-check. In the pharmacy, teams should use open-ended questions at prescription intake and pickup. They should use a counselling room, if possible, and encourage patients to call if they have questions. Pharmacy staffers should also use the time when they’re talking with patients about the medications to open the prescription containers and look at the medication’s appearance. That will give both the pharmacy staffer and the patient a chance to check the appearance of the product and spot any discrepancies. Read: ISMP Canada analysis highlights errors that can happen with look-alike high-alert medications

ISMP Canada: Pharmacies caught 700+ near misses in one month alone. Here’s what they taught us

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