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Reflection on practice: learning from near miss logs

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Reflection on practice: learning from near miss logs

Errors and mistakes will happen in the pharmacy, but it’s important that we learn from them, says Joanne Taylor

The dispensing process is, for many of us, one that we follow without a second thought; it becomes second nature. And, like other tasks we perform on a day-to-day basis, we perhaps don’t reflect on it as much as we could do. As part of their training, accuracy checking pharmacy technicians (ACPTs) look closely at the dispensing process, and the three-point accuracy check forms an important part of learning. It follows the process of checking the prescription, the actual medication and the label in three separate checks.

At Vittoria Healthcare, we encourage all staff to apply the three-point accuracy check, so that by the time the medication arrives for the final accuracy check, the person who has dispensed it has already performed their own personal primary accuracy check. If a near miss error is picked up at the final check, the member of staff is advised, and will then amend the error and make a note in the near miss log. We encourage all staff to complete their own near miss log so that an opportunity to learn can take place, not only for themselves but also for the rest of the team.The near miss logs we use are anonymous, so that the focus is on learning from the error rather than looking at the name of the team member. If there is a training issue or somebody is making repeated errors, we organise a training session for the whole team.

To ensure we learn from near misses, each branch holds a ‘reflection meeting’ every eight weeks to discuss the near miss logs with the whole team. The most common near misses are noted along with the most common contributing factors and ways to improve practice. Some of the ideas are ‘check strength’ and ‘check drug’ neon stickers applied to the shelf edge, as well as separating stock and highlighting similar packaging so that it can be clearly distinguished on the shelf. Other issues like reducing distractions and avoiding interruptions are also included in improvement plans.

The reflection meetings are documented and a copy is sent to head office with the near miss logs. These are audited and the results shared with the whole company, focusing on the type of common errors and ways to improve and learn from them. This means that learning and good practice can be shared and improved across the company. All levels of staff are included in the meetings, and we have found it a very positive way to promote a team approach in each pharmacy.

Joanne is a registered pharmacy technician and ACPT, and is professional standards lead at Vittoria Healthcare. She is national secretary for the Association of Pharmacy Technicians UK (APTUK), and is a member of the Medicines Rebalancing Programme Board at the Department of Health as well as TM’s editorial advisory panel.

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