An audit on patient safety in a community pharmacy using DATIX: reporting near misses

Abstract Introduction Pharmacy contractors are required to log patient safety events and report them a national system, currently, the Learn From Patient Safety Events (LFPSE) system.1 Professional guidance recommends that pharmacy staff record, learn, discuss, act analyse both dispensing errors near misses.2 The National Association defines miss as “patient incident is detected before or patient’s representative handed dispensed prescription preventing any unintended/unexpected harm”.3 This audit from single community in West Midlands region, provides baseline data on accuracy of DATIX system (a web-based platform) record incidents. Aim aimed establish if number incidents recorded paper equated over 4 week period. A standard 100% was set i.e. all logged should be entered onto DATIX. In addition, misses were analysed compared with same four period for previous five years. Methods Established company sheets used collection. For weeks November 2021, responsible pharmacist manually occurred pharmacy. At end each week, member volunteered input period, logs Head Office provided archived covering time Data descriptively using MicroSoft Excel®. Ethical approval not this an audit. Results percentage into 72%, therefore met (n = 46 versus n 33 DATIX). When paper-based collected store month analysed, it found 46) 0.29% prescriptions dispensed. Near most frequently Monday Tuesday least Wednesday. Analysis types identified picking wrong formulation frequent, followed by strength medicine. Four ‘look alike sound alike’ switches. years showed positive trend reported increasing 19 2017 2021. favourably average per across company; approximately double year year. Discussion/Conclusion Although small pharmacy, study highlights importance accurate recording so lessons can learned. Recommendations include further training use reaudit assess impact. References 1. Pharmaceutical Services Negotiating Committee. reporting [Online] Available from: https://psnc.org.uk/quality-and-regulations/clinical-governance/patient-safety-incident-reporting/ <Accessed 15/06/22> 2. Royal Society. Medicines, Ethics Practice. 44th ed. London: Society; 2021: 28-35. 3. Association. resources reporting. 9th April https://www.npa.co.uk/information-and-guidance/patient-safety-resources-on-incident-reporting/#:~:text=Near%20miss%20log%20%E2%80%93%20Record%20near,preventing%20any%20unintended%2Funexpected%20harm)