Background The Health System evolution has led to a transformation of roles and tasks traditionally assigned to the hospital pharmacist; he/she is now required to be an integral part of the healthcare team, in order to support both managed treatment and patient safety. The Veneto Oncological Institute IRCCS (IOV) of Padua has been selected as one of the five Italian centres of excellence in oncology taking part in the project sponsored by the Italian Ministry of Health (July 2010–February 2011), aimed at evaluating the contribution made by the continuous presence of a pharmacist in an oncology department. The monitoring and reporting of Near Misses was one of the outcome indicators of the project.
Purpose The aim of the project was to verify the contribution made by the pharmacist in the oncology department in Near Miss reporting.
Materials and methods A record of prescriptions (updated daily) was created to monitor all the following situations that could cause near misses:
▶ Sending a non-agreed statim prescription – Difficult to read prescription
▶ Incorrect date – Wrong dosage – Diagnosis not present or incomplete – Non-standardised prescription form
Each situation was evaluated in terms of risk. All high-risk prescriptions associated with a near miss were recorded as non-conforming to our Quality System.
Results A special register was established, in which the different causes of near misses are recorded.
From the creation of the register (October 2010) to 15 February 2011, 50 near misses were recorded classified by event as follows:
▶ sending a non-agreed statim prescription (17 cases)
▶ difficult-to-read prescription (20 cases; an incident reporting form was completed for one of them)
▶ wrong dosage (5 cases)
▶ mixed up labels (1 case)
▶ error in calculating the length of cycle (2 cases)
▶ wrong prescription (2 cases)
▶ wrong protocol used (3 cases: trastuzumab 2 mg/kg instead of trastuzumab 8 mg/kg)
Since November 1st 2011, prescribing has been computerised. The Oncosys medical record, after 18 months of validation, is the only prescribing system used at the moment in our hospital (IOV) for cancer treatment. Introducing the near-miss register is still in progress so a comparative evaluation of pre and postcomputerisation data was not yet possible. At present a reduction in near misses of up to 60% has been recorded.
Conclusions The recorded cases of near misses have stimulated the development of standardised protocols, computerisation of medical records and increased awareness of potential medicines errors in the physicians and other healthcare staff. The integration of department pharmacists in the multidisciplinary oncological staff significantly contributes to patient safety, ensuring appropriate prescribing and reducing medical errors and adverse drug effects. Moreover, cooperation within a multidisciplinary team enabled the shared setting up of a fully computerised and safe system for diagnosis and treatment.
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