With the busy season behind us, and many pharmacists returning to their regular routines, now is an ideal time to reflect on the past year, including any near misses or incidents that may have occurred—whether personally or among colleagues.
Some things to think about:
- What are some of the factors that might have contributed to the error?
- How did I handle it? Is there anything I could do differently next time?
- Who is responsible for reporting incidents?
- How are near misses/incidents reviewed to share learnings with the team and protect others from falling into the same trap?
- What are some measures that can be put in place to mitigate this?
PDL continues to receive a significant number of inquiries regarding wrong patient errors. These include incidents such as medicines being dispensed to the incorrect patient, incorrect patient labelling on medication, errors relating to Dose Administration Aids (e.g. pack labelling or delivery issues), mistakes in Staged Supply or Opioid Replacement Therapy involving patient selection or dosing, and vaccination-related errors.
Please refer to the Practice Alerts ‘Be aware or beware of wrong patient errors – part 1’ and ‘Be aware or beware of wrong patient errors – part 2’ for a detailed refresher about common contributing factors, examples, resources to assist in prevention, and safe practice recommendations from PDL.
A message from the PDL Professional Officers
PDL has developed the video below to help provide a clearer understanding of this error type, touching on our latest resource developed for further prevention.
PDL members can call 1300 854 838 for advice and incident support from one of our Professional Officers. Supporting our pharmacist members 24/7.
