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General and Risk Management, Patient Safety (including: medication errors, quality control)
Incident and malfunctions compendium at the pharmacy: review and analysis after 1 year of statements record
  1. C. Perrin,
  2. C. Boronad,
  3. M. Falcand,
  4. F. Birbes,
  5. S. Chanton,
  6. A. Gagot-Gandet
  1. 1Centre Hospitalier de Cannes, 06400, Cannes, France


Background The establishment of a recording and incidents processing system to the medication circuit is an important element in the risk management associated with drug therapy.

Purpose The aim is to identify adverse events, analyse the causes and consider corrective actions to reduce or delete dangerous situations.

Materials and methods A card for reporting adverse events and a registration database was established. This card can be filled by any staff of the pharmacy for incidents that had a proven or potential impact on the patient management or service organisation.

Results After 1 year, 255 statements were recorded. 87% of events have been reported by a pharmacist and 13% by a dispenser. 33% of the events involve a prescription problem (contraindications, wrong dosage…). 24% of incidents are related during dispensing (wrong product, wrong pharmaceutical form…). 18% of collected incidents indicate a malfunction in the pharmacy (stock error, storage error…). 4% of events are due to an organisational problem in the care services that have an impact on the pharmacy. 8% of declarations are due to a computer problem, 7% to a lack of communication between care services and pharmacy, 5% to a problem in the delivery to care services, and 1% to a security problem. On 255 statements, 33% are considered by declarants as having a potential impact on patient management.

Conclusions Immediate corrective actions are taken for serious incidents; the longer-term interventions were implemented to recurring malfunctions. However, no action is planned about incidents not directly related to the pharmacy. This approach is included in a global quality approach and improves the pharmacy operational system and thus, the patient management. Since the introduction of these cards, a staff awareness of the most frequent incidents is carried out. The authors have now to assess these actions impacts on dangerous situations.

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