Improving patient safety: Lessons from a regional pharmacist audit

The Midland Pharmacy Group's audit of prescription errors probably comes with no surprises for GPs.  

I hope I am not alone in reflecting that, at least once a day, I will have a note or call from a pharmacist asking me to update a special authority, or correct the formulation, or occasionally even the dose, of a medication I have prescribed. 

Our community pharmacist offers a great safety net to capture these issues and help keep us and our patients safe, They can add a lot of value to the patient who has another person to answer questions and pick up potential interactions between medicines.  

There are some key takeaways for general practice teams to think about.  

• This was an audit of prescription issues across 68 pharmacies, rural and urban in Te Manawa Taki, which sought to find prescription issues that needed pharmacist involvement.  
• It identified administration issues that caused greater workload, and highlighted the role pharmacists play in preventing patient harm through identifying prescription errors, and potential interactions between medicines.  
• Key to this was the interface between hospital and general practice and the patient - where patients are involved with multiple prescribers there is more chance for errors to arise.  
• 26 per cent of reported issues posed significant potential for patient harm if not intercepted by pharmacists.
• 15 per cent of issues were unresolved at the end of the audit week, potentially resulting in delays for patients receiving medications. 

GPs may find that pharmacists increase queries and requests for clarification, as a result of the audit.  

Prescribing policies and processes may be usefully reviewed - especially for remote team and "locum" team members who may be less aware of the personal factors and past medical history that can impact prescription safety.  

Good communication between pharmacies and general practice is vital.  

A single electronic health record (SEHR) which allows pharmacy, GP and hospital to all see the same information could make a big difference to the checking that pharmacies need to do.

Pinnacle has been working towards seeing HealthOne, a SEHR, into our region and it will be interesting to see if an audit in Te Wai Pounamu, where HealthOne has been in place for several years, would have the same results. 

In the meantime, we should continue to do all we can to reduce prescribing errors, especially when patient care is transferred between ourselves and hospital and specialist services.