dispensing error reporting

[museabuse]

I know technically anytime there is an error it is supposed to be reported, like in walgreens and cvs database. However what is considered an error?

For example I have come across a few times where my partner verified an rx under the wrong person like the spouse(usually because pt drops off multiple scripts and tech assumes its for the same person when entering), but they were caught and fixed when the pt came to pick it up. I didn't report this, is this considered and error and should I have reported it?

There have been times where I was verifying a refill and noticed something should have been an oitment and it was filled as a cream and I have changed it. Or a rx was written for HFA albuterol and filled with non hfa one or visa versa, or filled with augmented form, instead of the regular one, should these have been reported?

Then other things I have noticed and changed were things like wrong refills and miss spellings like BID on label instead of twice a day. Should I be reporting these things?



I know the easy answer is yes but at the same time couldn't this cause a lot of drama if I reported some little things, and then maybe cause some sort of revenge or witch hunt against me. I am sure I have let somethings by me too and don't want someone reporting me because I didn't see the refills were wrong.

Oh and it might sound like it is happening all the time but more like once or twice a month I had to change something.

I don't know what do you guys do in situations like this?

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[ForcedEntry]

It isn't an error unless it gets to the patient incorrectly.

 

[genesis09]

What you are describing is technically an internal error. It should be reported, but most do not report it.

 

[tussionex]

It isn't an error unless it gets to the patient incorrectly.

i second that. everything the OP mentioned is basically why we're here...to catch the mistakes before they reach the patient.

however, if it is a trend towards certain mistakes all the time, it may be a process issue and should be examined.

 

[Fenderplayer108]

I think it all depends on the pharmacist that is on duty when the mistake is caught. With the WAG's system, after making a report in stars, you can select an underlining cause, IE; Illegible handwriting, ect.. And it also has a section for the outcome, from patient healthy, all the way to patient hospitalized.

Now we have a pharmacist that I float with that makes reports for ANYTHING. No joke, if the doctor fax's back a refill request with the note "not our patient", then you better believe she will make a report about it.

I only report things that could potentially cause harm, and the things that may have caused harm. Not missing a refill, or selecting the wrong doctor from the list of 300 John Smiths...

 

[pharmacogenomic]

My advice is to ask your PIC or dop.

Reporting errors is a big issue, particularly outside the pharmacy. You want to be sure you know exactly how to fill out the form correctly.

Most incident reports are used these days as teaching tools. Certainly, if the error gets to the pt, it will be used in discovery as evidence of exactly what went wrong & who did what/when. That's why its important to know how to fill out the report since you may get to see it again in a courtroom setting.

In my hospital job, we fill out departmental only incident reports when an error is caught which does not go outside the dept (whether it got to the patient or not. We consider it an error even if it got to a nursing unit). We use these as teaching tools & there is an IT pharmacist who runs thru them to see if we have a system error which might be contributing.