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Mistakes do happen. This guidance and error log will help you, and your pharmacy team, to work through the mistake and learn from it. Regular reviews of near misses and action taken can prevent similar mistakes from happening in the future. The Society have produced this guidance to help support clinical governance in pharmacy. Before using the form it is recommended that you define what you think a near miss is within your pharmacy team. You will then all know what you should be recording and why.
Top tips:
- Designate a period of time in each quarter of the year to record near misses e.g. the first two weeks of every quarter.
- Establish a procedure of recording near misses that works for your dispensary.
- Ensure that the near miss record sheet is accessible to all staff when it is needed.
Error log
| Code | Type of Near Miss |
|
Options |
Things to consider | ||
| D | Wrong drug | • Product put away at wrong location • Product selected incorrectly • Products mixed on dispensing bench |
• Do the packs look similar? Should you separate? • Who puts away the goods? Training issues? • More than one Rx being dispensed at a time? • Are packs placed on shelf with contents visible? • Consider use of dispensing baskets? • Have you read the Rx correctly? • Do you dispense from the Rx & not the labels? |
|||
| E | Out of date product | • Out of date products on shelf • Are there any more on the shelf? |
• Are you carrying out a quarterly stock control? • Are you checking the expiry dates of medicines regularly? • Are you checking the expiry date when you pick the medicine off the shelf and carry out the final check? |
|||
| F | Wrong Form | • Inadequate prescription detail | • Misread prescription • Are you familiar with all formulations? • CPD issue? • Distractions? |
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| L | Wrong label | • Incorrect transfer of information from the Rx • Misread prescription • Labelling in batches |
• Errors likely when label selected from repeats on PMR • Are products dispensed and labelled one at a time? |
|||
| M | Missing item | • Products mixed up on dispensing bench • Fridge line / CD / Owing |
• Has the missing product been placed in another bag? • Consider use of dispensing basket • Warning label informing of fridge / CD line / owing still to come • Dispense and label one product at a time |
|||
| N | Wrong patient name |
• Incomplete Rx reception process • Previous patient selected from PMR • Identical patient names • Wrong patient selected from PMR |
• Staff training issues? • Distractions? • Warning for locums that two patients have the same name • Enough detail on PMR to deal with similar names? |
|||
| P | Misread prescription |
• Inadequate / ambiguous details • Hand-written prescription • Poorly performed Rx evaluation process |
• Training issue? • Visual impairment? • Was professional evaluation performed? |
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| Q | Wrong quantity |
• Incorrect transfer of information from Rx • Misread prescription or calculation error |
• Have you selected label from PMR or Rx? • Can someone else check your calculation? |
|||
| S | Wrong Strength |
• Product put away at wrong location • Product selected incorrectly • Products mixed on dispensing bench |
• Do the packs look similar? Should you separate? • Who puts away the goods? Training issue? • Are packs placed on shelf with contents identity visible? • Have you read the Rx correctly? Dispense from the Rx not the label |
Where to go for more information
Email: support@rpharms.com
Telephone: 0845 257 2570
Submit an enquiry about this topic.
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