Prospective systemic risk analysis of the dispensing process in German community pharmacies

Predicting dispensing errors in community pharmacies: An application of the Systematic Human Error Reduction and Prediction Approach (SHERPA)

Introduction

The objective of this study was to use a prospective error analysis method to examine the process of dispensing medication in community pharmacy settings and identify remedial solutions to avoid potential errors, categorising them as strong, intermediate, or weak based on an established patient safety action hierarchy tool.

Method

Focus group discussions and non-participant observations were undertaken to develop a Hierarchical Task Analysis (HTA), and subsequent focus group discussions applied the Systematic Human Error Reduction and Prediction Approach (SHERPA) focusing on the task of dispensing medication in community pharmacies. Remedial measures identified through the SHERPA analysis were then categorised as strong, intermediate, or weak based on the Veteran Affairs National Centre for Patient Safety action hierarchy. Non-participant observations were conducted at 3 pharmacies, totalling 12 hours, based in England. Additionally, 7 community pharmacists, with experience ranging from 8 to 38 years, participated in a total of 4 focus groups, each lasting between 57 to 85 minutes, with one focus group discussing the HTA and three applying SHERPA. A HTA was produced consisting of 10 sub-tasks, with further levels of sub-tasks within each of them.

Results

Overall, 88 potential errors were identified, with a total of 35 remedial solutions proposed to avoid these errors in practice. Sixteen (46%) of these remedial measures were categorised as weak, 14 (40%) as intermediate and 5 (14%) as strong according to the Veteran Affairs National Centre for Patient Safety action hierarchy. Sub-tasks with the most potential errors were identified, which included ‘producing medication labels’ and ‘final checking of medicines’. The most common type of error determined from the SHERPA analysis related to omitting a check during the dispensing process which accounted for 19 potential errors.

Discussion

This work applies both HTA and SHERPA for the first time to the task of dispensing medication in community pharmacies, detailing the complexity of the task and highlighting potential errors and remedial measures specific to this task. Future research should examine the effectiveness of the proposed remedial solutions to improve patient safety.

Application of failure mode and effects analysis (FMEA) to improve medication safety in the dispensing process - a study at a teaching hospital, Sri Lanka

Background

Failure mode and effects analysis (FMEA) is a prospective, team based, structured process used to identify system failures of high risk processes before they occur. Medication dispensing is a risky process that should be analysed for its inherent risks using FMEA. The objective of this study was to identify possible failure modes, their effects, and causes in the dispensing process of a selected tertiary care hospital using FMEA.

Methods

Two independent teams (Team A and Team B) of pharmacists conducted the FMEA for two months in the Department of Pharmacy of a selected teaching hospital, Colombo, Sri Lanka. Each team had five meetings of two hours each, where the dispensing process and sub processes were mapped, and possible failure modes, their effects, and causes, were identified. A score for potential severity (S), frequency (F) and detectability (D) was assigned for each failure mode. Risk Priority Numbers (RPNs) were calculated (RPN=SxFxD), and identified failure modes were prioritised.

Results

Team A identified 48 failure modes while Team B identified 42. Among all 90 failure modes, 69 were common to both teams. Team A prioritised 36 failure modes, while Team B prioritised 30 failure modes for corrective action using the scores. Both teams identified overcrowded dispensing counters as a cause for 57 failure modes. Redesigning of dispensing tables, dispensing labels, the dispensing and medication re-packing processes, and establishing a patient counseling unit, were the major suggestions for correction.

Conclusion

FMEA was successfully used to identify and prioritise possible failure modes of the dispensing process through the active involvement of pharmacists.

Application of Failure Mode and Effect Analysis (FMEA) to improve medication safety: a systematic review

Medication safety is a phenomenon of interest in most healthcare settings worldwide. Failure Mode and Effect Analysis (FMEA) is a prospective method to identify failures. We systematically reviewed the application of FMEA in improving medication safety in the medication use process. Electronic databases were searched using keywords ((failure mode and effect analysis) AND (pharmacy OR hospital)). Articles that fulfilled prespecified inclusion criteria were selected and were then screened independently by two researchers. Studies fulfilling the inclusion criteria and cited in articles selected for the study were also included. Selected articles were then analysed according to specified objectives. Among 27€706 articles obtained initially, only 29 matched the inclusion criteria. After adding four cited articles, a total of 33 articles were analysed. FMEA was used to analyse both existing systems and new policies before implementing. All participants of FMEA reported that this process was an effective group activity to identify errors in the system, although time-consuming and subjective.

The evaluation of malpractice cases arising from aesthetic intervention in Turkey based on Supreme Court case law

AIM

The aim of this study is to evaluate medical malpractice cases arising from aesthetic services based on the decisions of the Supreme Court.

MATERIAL AND METHODS

In the study, compensation and criminal lawsuits finalized by the civil and penal courts of the Supreme Court were examined retrospectively. All the case law decisions were obtained from the official website of the Supreme Court: www.yargitay.gov.tr. Nine hundred and eighty-one decisions were obtained after performing a keyword search in the website; after duplicates and unrelated cases were removed, 81 decisions (N = 81) were evaluated.

RESULTS

The analysis showed that lawsuits related to medical malpractice involving aesthetic interventions are mostly finalized by the civil courts, which decide claims for compensation. Malpractice primarily occurred in private hospitals and beauty centers, and operations were found to be commonly performed by physicians and beauty experts. Malpractice cases were found to be mostly caused by poor medical intervention, a lack of attention/care, and faulty/incorrect treatment. The average compensation amount provided by the civil courts is 55 558 ± 50 014 TL (14 209 ± 12 318 USD).

CONCLUSION

On the basis of these results, it is recommended that the awareness and training level of healthcare personnel should be increased, and precautions should be taken at both the institutional and the national levels.