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

Abstract

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