Learning from our mistakes – how medicine errors helped us improve how we do things

22 January 2020
By AnnaMarie Felice - Nurse Clinical Lead RGN RMN NMP

Keeping people safe is one of our most important priorities. We support our colleagues to make sure they are helping people in a safe and effective way. We want to make sure everyone who uses our services is confident they’ll be well cared for. However, there are sometimes difficulties with how we prescribe medications and how we communicate with our pharmacy partners. This can have an impact on people who use our services.

To make sure we’re always improving and learning from mistakes, my colleagues at Spectrum Drug and Alcohol Recovery Services and I looked at 65 prescribing errors that had taken place over 3 months. We explored why they happened, and how to stop them happening again. We shared what we found with clinical staff and local pharmacy partners, so everyone could learn how to improve how they work.

What went wrong?

When the team and I looked into the errors, we found a few common problems. These included:

  • Prescriptions sent to the pharmacy more than once.
  • Prescriptions posted to the wrong pharmacy.
  • Multiple prescriptions issued with the same date.
  • Prescriptions were not cancelled when someone had asked for them to be.
  • A prescription for medication taken under supervision by a pharmacist was sent to the wrong pharmacy.
  • A prescription not collected by the person in treatment.
  • Holiday prescriptions were incorrectly recorded.

For example:

  • In one case a person who had been discharged from hospital was given prescriptions by both the hospital and the community service on the same day.
  • In another case, someone transferred to a new pharmacy, but was able to collect prescriptions at their new and old pharmacies on the same day.
  • Another person who was held in custody was able to send a police officer to collect his prescription, even though he had stopped collecting them himself.

Luckily, none of these errors led to any harm to the people involved. But all of them could have been avoided if our service and the pharmacies were communicating more clearly.

What did we do to improve?

  • We shared the findings and lessons with staff at Spectrum and local pharmacists.
  • When stopping prescriptions, we asked our staff to always note down the name of the pharmacist they talk to. They should give the reason for ending the prescription(s) and agree which prescriptions need voiding by confirming against the prescription numbers.
  • We reminded pharmacists not to dispense opiate medication if someone has missed it for 3 days.
  • If someone has been discharged from hospital, we asked community pharmacists to always check the medicine the hospital team has given them before prescribing anything.

These errors show that we should always be looking for ways to improve how we do things. We must look carefully at any mistakes, learn from them, then share that learning among staff and partners. If we do this, we can improve how we run things, stop the mistakes from happening again, and make things safer and easier for everyone.

If you’d like to ask any questions or find out more, please feel free to email me via [email protected].