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GPhC should collect information on dispensing errors, says academic

The GPhC should use evidence it receives on dispensing errors to understand how to prevent them, says health psychologist Hannah Family

The regulator could use data it receives to create the "perfect dispensary environment" and prevent mistakes, says health psychologist Hannah Family

The General Pharmaceutical Council (GPhC) should gather information on dispensing errors to make pharmacies safer, a leading academic has said.

The regulator could use evidence it received about dispensing errors to understand why they occurred and help create the "perfect dispensary environment", Hannah Family, lead author of a study into the causes of errors in community pharmacies, told C+D yesterday (September 10).

The study, which was published on Monday (September 8), found that two thirds of community pharmacists and three quarters of pharmacy students failed to detect every dispensing error. Distractions in the pharmacy had a "negative impact" on a pharmacist's ability to detect errors, it said.

In the study, pharmacists and students carried out final accuracy checks on a set of 50 pre-dispensed items, five of which contained errors. Only 35 per cent of community pharmacists and 25 per cent of students were able to detect all of the errors.

Pharmacists were often distracted by assisting patients with "irrelevant tasks" during the dispensing process and it would be helpful if the GPhC used its contact with all pharmacists and technicians to provide more insight into the factors causing dispensing errors, said Ms Family, a lecturer in health psychology at Bath University.

"This might be contentious as [the GPhC] haven't had that role in the past, but it could be good if they supported pharmacists [with] evidence that made their work safer," she added.

The GPhC told C+D that it did not "routinely collate" figures on dispensing errors as this responsibility lay with NHS England, which oversees the National Reporting and Learning System.

The study recommended that pharmacies should prioritise reducing interruptions and distractions in areas where medicines are prepared. This could be done by creating barriers around areas where critical work was being carried out and asking pharmacy staff to avoid interrupting colleagues if they were dispensing a prescription, it said.

Heidi Wright, Royal Pharmaceutical Society practice and policy lead for England, agreed that it would be helpful if the GPhC made use of the evidence it received about dispensing errors, as this information "isn't currently shared".

Pharmacy teams should also be trained about the risks of being distracted, said Ms Wright, who suggested that dispensing processes should be designed to minimise the risk of errors.

The study also showed that pharmacists were more likely to miss labelling errors than errors relating to the wrong type or amount of medicine. However,it did not reveal any correlation between mental workload - the number of tasks an individual is thinking about - and the rate of dispensing errors, the authors concluded.

How common are distractions when you are dispensing? 

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Uma Patel, Community pharmacist

Typical acedemic. Get real. Multi tasking is inevitable in a dispensary.
There is no such thing as perfection.
In every process there will be errors.
We do all we can to minimise them

[email protected], Community pharmacist

Poor, poor, misguided academics.

First off, a big shout out of congrats/ well done to the third of community pharmacists and quarter of students who spot every error.

The GPHC could use this data about errors "to understand why they occurred and help create the "perfect dispensary environment". COULD. It will more likely use it to penalise pharmacists and pharmacies. Ms Family, if you need proof, then read some articles in the pharmaceutical press.

So this study has shown us that "Distractions in the pharmacy had a "negative impact" on a pharmacist's ability to detect errors".
Distractions a negative impact, well I never. That's where we have been going wrong. It is nice to have a study revealing such information, whereas 10 minutes in any pharmacy would have made this obvious it is still nice to have a study. "Look" we can now say "We have a study".

"Pharmacists were often distracted by assisting patients with "irrelevant tasks"". I tested this out today, I told several, now former, customers that their questions were irrelevant and to stop distracting me. It worked. No distractions. No customers. I had a much more peaceful and less stressful day. I’m sure we’ll have a study come along soon on how to keep customers but this is a good first step.

I am sorry to just copy out whole sections of this article but I can't help myself.
"The study recommended that pharmacies should prioritise reducing interruptions and distractions... by creating barriers around areas where critical work was being carried out and asking pharmacy staff to avoid interrupting colleagues".
So what about all that dispensing in front of the customer? Opening up the pharmacy, reducing barriers to encourage communication and openness? Well we now have a study, so we can board up the dispensary, letting only one member of staff through at a time. Should we get rid of the phone too? I mean it is only problems when it rings.
Should we get staff slippers? Footsteps can be so annoying, don't you think?

Let's tell customers to shush when they come in, treat the pharmacy like a library. Library, you know what I mean, yeah that building over there, the one that no one goes in nowadays.

Sorry, things took a weird turn there at the end.

I really don't know, I appreciate we now have a study but I do despair sometimes.

I wonder if we could have a "Study on Studies of the Obvious", and whether these studies achieve anything other than stating the obvious because well everything the say is, you know, obvious.

Calum Nelson, Locum pharmacist

Whatever happened to this booklet?

They might be a few years old now, but I'm sure it's still relevant.

Claire Knight,

We have developed a really simple piece of software called Dispens-IT that is used in hundreds of dispensing GP surgeries. It negates human error by using the barcodes on the medication packs.
We have often thought of promoting its use in pharmacies - is anyone interested in helping us do this? If so, please contact us.

Melanie McLeod, Primary care pharmacist

A similar system is also used in Australia as a check when dispensing and although it adds another step to the dispensing process it works well as a product check.

Philip Caton, Community pharmacist

If you'd worked in a multiple or a supermarket you would know that barcodes are not infallible and could actually lead to complacency and an over reliance on IT. That in my opinion would be more dangerous, not less. Besides there is a bit more to dispensing than that and dispensing doctors play by a totally different set of rules. But that is another debate altogether........

[email protected], Pre-reg graduate

First things first. There is a huge difference between how GP surgeries work and how Pharmacies work. Second, there is again a HUGE difference between a Prescription and a box of Tablets. A prescription with 3 items and a barcode cannot/ will not change to a prescription with only 2 items when it is printed. But, a box of Amlodipine 28 tablets (when scanned with barcode) can be dispensed as only 14 tablets if it was a split pack and someone did not follow the SOP for split packs. We are talking about HUMAN ERRORS not computer errors. The errors that happen most of the time in the Pharmacy are due to extra work pressure and less staff and using bar-code scanning can only add to the work load than improving the work conditions.

I really don't see why everyone is being so anti-academic here.

Its only by having good, robust evidence of the problems that face community pharmacists that anything will ever get done. Without research like this, we can't back up any of our complaints about workload, staffing levels, distractions etc. Community pharmacists don't have the time to do the research themselves. I am personally welcoming this study, which helps back me up when I say i need enough staff and a proper environment for checking prescriptions in.

Meera Sharma, Community pharmacist

Hayley, the theory bit sounds great - but I agree with the other readers that the evidence that may be collated may be manipulated to create more work, by multiples to discipline their pharmacists and who knows even the GPhC towards individual pharmacists!

One only has to pick up the pages of any pharmacy publication to assess what environment most pharmacists are working in and that is what is leading to the errors. Yet, not even one pharmacy body has acknowledged this.

Let's be careful what is collected in the name of evidence - could be used as a double-edged sword!


In simple english......

Errors could be cut back to negligible if only Pharmacies had the proper staff numbers and provided adeqoute breaks..... This will ONLY happen if pharmacists have the guts to use their tongue and speak out
As the BT advert goes starring Maureen lipton - ITS GOOD TO TALK


Mz Johnson...You are living in cloud cuckoo land as always....

All that needs to take place is for a GPHC inspector to spend a day at a Pharmacy to understand the problems, the running around contractors do, out of stock, items, missed medications by surgeries, surgeries not printing off correct items, NOMAD TRAYS, lack of staff, lack of tea breaks, pressure to perform MURs, NMS, problems with EPS etc etc

You quote about it helps you back up your requirement for enough staff has been spoken about for years.......THE GPHC ARE NOT BOTHERED ABOUT THAT!!!....
This has been a problem for many years......It is nothing new....

Peter McAuley, Community pharmacist

In theory, this is correct.
I quote from the above 'But the GPhC told C&D this responsibility lay with NHS England, which oversees the National Reporting and Learning System'.
I dispute this statement about a Learning System.
There is a reporting system, but no learning system. Nothing ever comes back from these online reports, wherever they should originate (Area teams?). We cannot see what mistakes other pharmacists are making (anonymously) and what they are doing to correct them from happening again..
This is how we learn, seeing how others correct their systems to improve.

Tariq Atchia, Pharmacy Area manager/ Operations Manager

Historically the NRLS has had limited feedback on dispensing errors but I believe the tide is changing. Through the establishment of medication safety officers in hospitals, multiples and large pharmacy organisations, the NRLS is courting further involvement of pharmacy and it's up to them to push the data back down the line and disseminate learning through the networks.

Reporting errors will be a key part of the decriminalisation of dispensing errors under the rebalancing medicines legislation programme - Lord Howe alluded to that in his speech to the RPS conference on Monday and it's a common theme message throughout the output from the rebalancing medicines legislation board so far.

John Alan James Robinson, Superintendent Pharmacist

I dont disagree with this. But the statistics may not ultimately lie with the learning part but may be used to beat us with another stick. Mistakes , genuine errors are often made because of pressure which may be because of underfunding. Is it 3 years now that DH have failed to settle. What happened to COSIi ? An offer letter to PSNC was presented to PSNC prior to March of this year according to a reliable source quoted in these pages. Nothing happened. Yet we are still being loaded with yet more regulatory burden. It seems that the element of trust has disappeared. Knee jerk reactions are the order of the day. Politicians cant be trusted, doctors ,Nurses, pharmacists cant be trusted. Then we have whistleblowing which can only lead to more mistrust. Meanwhile the prescriptions need dispensing. What luxury to spend so much time with academic machinations. I was an academic , I

Hitesh Patel, Community pharmacist

Academic! -says it all, probably never seen the in side of a dispensary.

There will always be human error, and our job is to minimize these, and lets face it, you don't need post graduate qualifications to work that out nor GPHC inspectors to collate dispensing error data.
Come and work in my hell hole and see if you can have a "perfect dispensing environment"!!!!!!!!!!!!!!!

John Alan James Robinson, Superintendent Pharmacist

Academics , politicians and academics. Those that don't know are informed by those who know but may have never worked at the coal face. Others legislate on the basis of what the experts tell them. Regulators then audit and enforce. Those with first hand knowledge responsible for "the doing" may be consulted. or not. The public are consulted rapidly. In the end there is little that changes and yet more pressures are put on a profession that is intrinsically sound. The only memorable event even today is the peppermint water case.
Meanwhile a shedload of money is spent so that politicians can say how safe society is.
Money better spent on a proton beam accelerator methinks.

M Yang, Community pharmacist

In theory, it's a good idea but it must be implemented in such a way that it doesn't increase the Pharmacist's workload unnecessarily. Trying to introduce anew IT that requires Pharmacists and support staff to undergo extra training would not be welcome and would only create more work. The onus should should be on the GPhC, who should look at the data collected by existing IT that pharmacies already use to report dispensing errors.

Furthermore, from personal experience working for a mulitple, I would think any new route of reporting dispensing errors is likely to become another box ticking exercise vigorously forced on the workforce by management. Deviation from it would illicit a harsh response. Management would likely use it as extra ammo against their employees during disciplinaries.

I know this sounds awfully cynical, but this is our reality. It's the big bad multiples versus everyone else. Let's not try and deny it.


Treating the symptom and not the cause

majority of errors due to lack of staff - reminds me of an episode of only fools and horses where del says you rodney

AND YOU WASTED INK FOR THAT ....................

Reeyah H, Community pharmacist

Totally agree!

Kevin Western, Community pharmacist

what a wonderful life it must be being an acedemic. Can we have funding to study acedemics and see how they could improve their output, with removal of status if they get it wrong?
I am sure that there are ways that could make Pharmacies safer environments but in all things there is a balance , and we are after all human - we can get it 99% right even 99.9% possibly 99.99% but there WILL be an error rate. all we can do is take reasonable steps to prevent them.
I cannot see how a one size fits all method would work without removing patint access from the process.

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