Johnathan Laird
IF a pharmacist says that they have never made a dispensing error I am afraid it is most likely that they are lying.
We train for five years to learn how to support patients to use their medicines safely. The personal and professional horror then of making your first dispensing error is profound. The impact psychologically on a newly qualified pharmacist should not be underestimated.
These situations are one of the purest tests of the professionalism of a pharmacist. Our patients rely on us behaving impeccably. In fact they expect it…and so they should. First do no harm…
The airline industry in my view are the world leaders in managing risk and learning lessons from critical incidents. The Comet aircraft was a good example of one such hard learned lesson. In the early 1950’s three Comets broke up in mid air reasonably early in their service life. The cause was metal fatigue. As the aircrafts ascended and descended they were exposed to differences in pressure which in turn caused the fuselage to expand and contract ever so slightly on every flight. In the same way that if you bend a spoon back and forth enough times the metal eventually broke.
Lessons were learned and modifications, like changing the window shape from square to round, were made. The Comet flew on and the basic design of aircraft ended its existence recently as the RAF Nimrod.
The story of fatigue did not however end there because in the late 80’s a Boeing 737 succumbed to the same fate as a result of metal fatigue. Admittedly the accident happened much later in the service life of the more modern Boeing than the Comet, but happen it did.
Lessons were again learned and since then it was decided that the level of fatigue should be regularly monitored on commercial aircraft.
The point here was that each accident was reported, the circumstances/causes were analysed and then alterations to practice were implemented with the aim of reducing the chance of the same thing happening again. Countless lives were saved no doubt as a result.
The dispensing of medicines is an inherently risky business. However by following the lead of the airline industry we can reduce this risk significantly and in my view prevent harm or worse.
As in many areas the Royal Pharmaceutical Society (RPS) leads the way in supporting pharmacists to develop their professional skills. The new tool from the RPS is very useful to support pharmacy teams to drill down to find the root causes of errors made in the dispensary in a similar way to that of the airline industry.
http://www.rpharms.com/unsecure-support-resources/near-miss-errors.asp?
The outputs of this process are usually quite simple. For example a responsible pharmacist might choose to separate similar looking drug packets on the shelf or take a fast moving drug up to eye level to prevent picking errors. The aim being to reduce near misses and therefore reduce the chance of a dispensing error.
The dispensing process is at times fast paced and stressful so human error will unfortunately happen.
I do think, however, if as professionals, we consider the process of dispensing a drug, a little like stepping on a plane it appears in a different light.
After all when we jump on a plane to go on holiday, we all expect to safely reach our destination.
Johnathan Laird is a community pharmacist independent prescriber with a special interest in asthma. He is based in based in Aberdeen and on twitter @JohnathanLaird