Pharmacists pick up 1257 mistakes in prescriptions in a week

More than one in four prescription errors picked up by pharmacists had a potentially serious risk of harm to patients, an audit has found.

Key facts:

In total, 68 pharmacies in the Midland Region took part in the week-long Script Audit – the first exploration of electronic scripts in New Zealand – using a purpose-built reporting app.

The Midland Region covers areas like Waikato, Lakes, Bay of Plenty, Taranaki, and Tairāwhiti.

Midland Community Pharmacy Group chief executive Pete Chandler – who co-ordinated the audit and built the app for it using AI – said a major driver for the initiative was the tragic death of a two-month-old baby in Manawatū earlier this year.

This came on top of long-standing concerns among pharmacists about system-wide clinical risk, he said.

“That was a wake-up call for pharmacists around the country to the fact that if they miss something on the script, the consequences can be tragic.”

In Bellamere Duncan’s case, it was an error at the pharmacy – but pharmacists say in most cases, they are the ones picking up problems.

During the week-long audit, pharmacists reported 1257 problems in prescriptions sent by GPs, specialists, midwives, dentists and other prescribers.

The most common related to inaccurate drug doses, followed by wrong quantities, missing details or patients prescribed “inappropriate” drugs, which could interfere with other medicines they were taking, for instance.

Most disturbingly, 26% of mistakes had a high risk of patient harm, if the pharmacist had not intervened.

The estimated rate of “interventions” varied widely between individual pharmacies, ranging from problems found in fewer than 1% of scripts to some identifying problems with 11.25% of total prescriptions sent to them.

The report noted the pharmacies with the highest intervention rates were known to the leadership teams of Bay of Plenty Community Pharmacy Group and MidCentral Community Pharmacy Group as “highly competent and thorough in clinical checking”, which suggested it could reflect more robust identification.

“Pharmacists have become the default safeguard against electronic deficiencies and other prescribing issues, yet this safeguard is neither resourced nor acknowledged in current funding or workforce planning. This is happening at a time when pharmacists should be contributing far more to reducing hospital and primary care pressures.”

Chandler said whenever there was a problem with a script, pharmacists had to contact the prescriber involved and sort it out – and that could take minutes, hours or even days.

“You can see the minutes ticking away into hours while the pharmacist is waiting for a response.”

This could involve trying to track down a junior doctor who had now finished a hospital shift, or getting through to a busy GP.

“Some things are just irritating rather than being unsafe. So if your barcode won’t scan, it’s a pain and it wastes time. If a patient’s details don’t come through on a script, it needs chasing up.

“There are a range of issues that can happen, but this is time that we really need to use for something else.”

Invisible work of pharmacists not funded

A smaller survey of 20 pharmacists by the Pharmaceutical Society earlier this year found 45% were making up to five clinical interventions every day and 6% were making up to 40.

North Shore pharmacist Michael Hammond, president of the Pharmaceutical Society, said problems with scripts were annoying for everyone involved, including the patient having to wait for it to be sorted out.

“There are supply chain issues as well, so we’re having to have conversations with patients about why something is out of stock and then go to the prescriber and explain they need an alternative, or they can only dispense one month’s supply.

“So there’s a lot of unseen activity by pharmacists that needs to be recognised and funded appropriately.”

While electronic prescribing had fixed the historic problem of illegible handwriting, this audit revealed that technology had spawned a new set of problems.

The report on the audit found training, knowledge of drug changes and the inherent complexity of patient care remained contributing factors.

“However, the scale and pattern of findings indicate that IT system flaws do appear to be responsible for a substantial proportion of script issues increasing the workload and risk for both pharmacists and prescribers.”

Pete Chandler said it was frustrating for everyone involved.

“Often what the GP thinks they’ve asked for is not what the pharmacist sees. And pharmacists are obsessively diligent in their work, they’re very careful people, so they will do what it takes to sort it out.”

GPs also frustrated

The College of General Practitioners medical director, Dr Prabani Wood, said none of the software systems available were completely fit-for-purpose.

“There aren’t really those fail-safe mechanisms in our electronic health systems that stop you from making a crazy error by multiplying the number of tablets you’re asking for by a factor of 10 or 100. That still doesn’t happen.”

While Health NZ was working towards a shared digital health record, it was almost impossible for busy GPs to keep up with which medicines were currently funded by Pharmac or subject to supply problems, she said.

“I did a prescription last week for a person with ADHD and they are on a number of different medications and different doses, a couple of which were available at their normal pharmacy and one that isn’t. So it gets quite tricky.

“The system is not in place to help things run more smoothly. For me, I think having easier communication between general practice and pharmacy would help.”

The report itself concluded that many of the problems reported could be significantly reduced with coordinated action and “a willingness to address root causes rather than relying on workarounds”.

Promising micro-improvements were already emerging, including a dedicated text-only line for pharmacy prescription enquiries at one GP practice.

However, systemic improvement would require some national level, some regional level and some local level (i.e. local pharmacy and general practice) quality improvement, including working with IT providers to improve their systems.

“This small snapshot validates the significant concerns pharmacists across Aotearoa have been signalling for years – that script issues are increasing, clinical risk is rising and the system is not responding to make at the pace required.

“Doing nothing is no longer a defensible option.”

rnz.co.nz