Background Prescribing, dispensing and associated errors may cause serious consequences for patients, occasionally fatal. Reporting errors has significant educational benefits and is a part of risk management. We have found few examples of educational tools being used to increase reporting rates. It was also felt that the present rate of error reporting is inaccurate.
Purpose To increase the reporting rate of errors by the introduction of educational tools and to improve standards in prescribing.
Material and methods Reporting data were collected over an initial 10 week period to create a baseline.
There were three areas of reporting:
pharmacy reporting on departments and
departmental reports on the pharmacy.
Three educational tools were then introduced: o project explanation (all areas); o prescription writing standards (physicians only); o anonymous reporting forms (all areas).
Data were re-collected after a second 10 week period.
Results Internal pharmacy reporting increased by almost 300%, mainly in two areas, ‘cytotoxics’ and ‘others’; the latter identified as mainly the incorrect use of equipment.
Pharmacy reports on departments increased by 100% plus. The number of reports was also high.
Departmental reports on the pharmacy increased by 30%. The majority were identified as basic administrative errors. The number of reports was low.
Script errors increased by 140% from the first to the second period, but the total prescription numbers dispensed during the two periods did not significantly change.
There has been a significant improvement in error reporting rates. All educational tools have contributed; anonymity and an increased awareness being considered as major contributors.
The acceptance of the explanatory and education tools by some departmental staff was found to be difficult, and this may in part explain their low rate of reporting.
A review of practice initiatives and improving the different methods of communication between departments are under way in order to improve standards and increase patient benefit.
The increase in prescription errors may be due to three possibilities: (1) an increase in reporting; (2) an increase in errors; or (3) a combination of the two. Further investigation is required to explain the possibility of a decrease in prescribing standards.
ConclusionNo conflict of interest.
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