Internal reporting system to improve a pharmacy's medication distribution process

Area of Science:

• Pharmacy Practice
• Patient Safety
• Healthcare Quality Improvement

Background:

• Existing institutional pharmacy occurrence-reporting systems may not capture all medication-related events.
• Identifying and analyzing medication errors and near misses is crucial for improving patient safety and healthcare outcomes.

Purpose of the Study:

• To review the current pharmacy occurrence-reporting system.
• To develop and evaluate an internal procedure to enhance data collection for improving the medication-use process.

Main Methods:

• A departmental occurrence-reporting system was implemented over nine months in a tertiary care academic center.
• Pharmacy staff surveys were used to assess the current reporting process and identify areas for improvement.
• A paper-based reporting form was developed, followed by the inclusion of pharmacist order entry.

Main Results:

• The internal system documented 1385 pharmacy events, compared to 203 dispensing errors reported to the hospital system.
• A significant increase in occurrence reporting was observed.
• At least 204 reported events involved high-alert medications.

Conclusions:

• An internal pharmacy occurrence-reporting system effectively increases staff reporting of medication events.
• This system identifies specific areas for improvement within the medication distribution process that might otherwise go unreported.