Pharmacies Prevent Over 700 Near Misses in One Month - 'No Harm Occurred'

By Larry Coté, Managing Director, Lean Advisors Inc

In April 2023, Safe Medication Practices (ISMPC) reported that community pharmacies managed to prevent over 700 near misses—incidents that could have potentially harmed patients but were caught before causing any damage. It is important to acknowledge that these 700+ incidents are limited to the ‘reported’ cases in a sample month, meaning the actual number may be different and possibly higher.

Types of errors detected included dispensing medications to which patients had allergies, prescribing drugs that look or sound alike incorrectly, issuing duplicate prescriptions for different patients, incorrect dosages, wrong medications, incorrect prescribers, and erroneous strengths or concentrations.

Another positive aspect is that most of these errors were identified by pharmacists, either during the initial filling or through a secondary review. Other staff members, as well as prescribers, patients, or caregivers, also played a role in intercepting some of these mistakes.

While it's not possible to determine the exact percentage of errors or near misses, the 700+ reported incidents underline the critical need for increased vigilance. In addition, understanding how many errors go undetected and reach patients' homes or care facilities is unknown (but would be interesting to know).

• Here are several solutions that were proposed in the article:
• Having two pharmacists handle each prescription—one to fill it and another to verify,
• Ensuring dispensers ask the patient several questions, including their birth date and weight,
• Keeping patient records updated, particularly concerning non-prescription medications and allergies,
• Using technology like bar codes for verification and alerts for drugs that look or sound alike
• Training all staff on proper procedures and patient interactions.

Implementing these strategies demands vigilance from multiple parties, including patients themselves. Ideally, such practices should become standardized processes but will not be relied upon to solve the root causes.

The core question should be: why not focus efforts on preventing errors from happening in the first place, instead of conducting multiple audits later in the process to catch the error? If needed, you could do both prevent errors and audit.

The key is to shift efforts from error detection to prevention.

There are tools and methods available to prevent mistakes from happening in the first place. Common mistake-proofing tools, visual controls, FMEA, 5S methodology etc. can be effectively adapted to the pharmaceutical industry.

The ultimate goal should be to reduce those 700+ mistakes to zero. And this can be accomplished through proper analysis and implementation of the ‘right’ tools. And it can be done without adding any more people and cost to the process!

By achieving this, everyone involved — pharmacists, doctors, caregivers, families, and patients—will feel safer, more confident, and less stressed, knowing that they are distributing and receiving the correct medications. Additionally, this will lower costs for pharmacies, caregiving facilities, and patients' families while ensuring more timely delivery of medications.