Adrian Boucher1, Certina Ho2, Neil MacKinnon1, Todd A Boyle1, Andrea Bishop1, Paola Gonzalez1, Christopher Hartt1, James R Barker1. 1. Leslie Dan Faculty of Pharmacy (Boucher, Ho), University of Toronto; Institute for Safe Medication Practices Canada (Boucher, Ho), Toronto, Ont.; James L. Winkle College of Pharmacy (MacKinnon), University of Cincinnati, Cincinnati, OH; Gerald Schwartz School of Business (Boyle), St. Francis Xavier University, Antigonish, NS; IWK Health Centre (Bishop); Rowe School of Business (Gonzalez, Barker), and Department of Business and Social Science (Hartt), Dalhousie University, Halifax, NS. 2. Leslie Dan Faculty of Pharmacy (Boucher, Ho), University of Toronto; Institute for Safe Medication Practices Canada (Boucher, Ho), Toronto, Ont.; James L. Winkle College of Pharmacy (MacKinnon), University of Cincinnati, Cincinnati, OH; Gerald Schwartz School of Business (Boyle), St. Francis Xavier University, Antigonish, NS; IWK Health Centre (Bishop); Rowe School of Business (Gonzalez, Barker), and Department of Business and Social Science (Hartt), Dalhousie University, Halifax, NS certina.ho@utoronto.ca.
Abstract
BACKGROUND: Quality-related events are defined as medication errors that reach the patient (e.g., incorrect drug, dose and quantity), in addition to medication errors that are intercepted before dispensing (i.e., near misses). The aim of this study is to quantify and characterize such events as reported by community pharmacies in a Canadian province. METHODS: A retrospective analysis was conducted on quality-related events reported to the Community Pharmacy Incident Reporting system from 301 community pharmacies in Nova Scotia between Oct. 1, 2010, and June 30, 2017. We performed a descriptive analysis on these events with respect to the discoverer, patient outcome, medication system stages and type. RESULTS: We identified 131 031 events reported by community pharmacies in Nova Scotia over the study period, 98 097 of which were quality-related events. Overall, 82.0% (n = 80 488) quality-related events did not reach the patient, and 0.95% (n = 928) were associated with patient harm. Incorrect dose or frequency, incorrect quantity and incorrect drug were the most common types of quality-related events reported. Most of the quality-related events occurred at order entry, followed by preparation and dispensing, and prescribing. INTERPRETATION: Quality-related events reported by community pharmacies differ from those reported in institutional settings with respect to patient outcome, medication system stages and type. This analysis provides valuable information to guide quality improvement initiatives to strengthen medication safety in community pharmacies. Copyright 2018, Joule Inc. or its licensors.
BACKGROUND: Quality-related events are defined as medication errors that reach the patient (e.g., incorrect drug, dose and quantity), in addition to medication errors that are intercepted before dispensing (i.e., near misses). The aim of this study is to quantify and characterize such events as reported by community pharmacies in a Canadian province. METHODS: A retrospective analysis was conducted on quality-related events reported to the Community Pharmacy Incident Reporting system from 301 community pharmacies in Nova Scotia between Oct. 1, 2010, and June 30, 2017. We performed a descriptive analysis on these events with respect to the discoverer, patient outcome, medication system stages and type. RESULTS: We identified 131 031 events reported by community pharmacies in Nova Scotia over the study period, 98 097 of which were quality-related events. Overall, 82.0% (n = 80 488) quality-related events did not reach the patient, and 0.95% (n = 928) were associated with patient harm. Incorrect dose or frequency, incorrect quantity and incorrect drug were the most common types of quality-related events reported. Most of the quality-related events occurred at order entry, followed by preparation and dispensing, and prescribing. INTERPRETATION: Quality-related events reported by community pharmacies differ from those reported in institutional settings with respect to patient outcome, medication system stages and type. This analysis provides valuable information to guide quality improvement initiatives to strengthen medication safety in community pharmacies. Copyright 2018, Joule Inc. or its licensors.