I wrote this article in response to Johnathan’s article: Dispensing errors happen: what can we learn from the airline industry to prevent them?
Great commentary Johnathan!
As well as incident reporting and analysis, we also need to be mindful of the ‘right first time’ principle and embed this into our training. A structured, focussed approach is essential to all our dispensing and checking activity, and we are starting to provide much more of this to support colleagues from day one.
Taking your airline analogy, it is also key that we regularly monitor fatigue amongst our staff (the aircraft in our industry that keep our services flying). Self-monitoring and self awareness is a good start – but also regular task rotation and breaks should be factored into workload models to avert potential fatigue.
From the airline example, we saw 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. The RPS tools are really useful if you haven’t already got systems in place. We need to create a culture where these a habitually used as part of the course of routine practice. Maintaining your own errors/near misses log is also helpful as reflection sand learning.
Lastly – I feel we are starting to move in the right direction to a culture of openness and sharing. It is great to see that Pharmacy Voice held a Patient Safety Event in Leeds in November last year. We need to share more of the great work that is happening!!
Gill Risby is the lead for pharmacy technical and support staff development for Yorkshire and Humber at the University of Leeds
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