愛污传媒

Every day, pharmacists find errors on physician prescriptions; most are corrected and quickly forgotten. Now a new study is counting those errors -- and the results are surprising.

Under a unique program, pharmacists in Nova Scotia are now tracking and reporting what they call "near hits" - those mistakes that patients never hear about but ones that -- had they not been caught -- could have sent the wrong medication or the wrong dose to a patient.

The ongoing study recruited 13 pharmacies across Nova Scotia, asking workers there to keep track of the errors and near-errors they encounter. They were then asked to report the errors anonymously using an online reporting tool.

In just eight months, the pharmacists at the 13 drug stores have reported 813 potential medication errors.

Dr. Neil MacKinnon, an associate professor at the College of Pharmacy at Dalhousie University, helped launch the study, called SafetyNET. He notes that all of the reported errors were caught in time and corrected before they got to the patient.

He says that with 422 million prescriptions dispensed in Canada every year, understanding the scope of the problem or errors will give pharmacists valuable new insight.

"If an error is never reported, we can never learn from that error," he explains to CTV.

MacKinnon notes that the problem with medication errors within the hospital setting is well understood and improvements are being made. But the problem of prescribing errors uncovered at the local community pharmacy has been little studied.

"The fact is there is no national reporting system, so at this point, I can't tell you how many prescribing errors happen in Canada," he says.

The most common errors caught so far by the SafetyNET study have involved dosage problems. Other problems have included:

• illegible handwriting from the prescriber
• problems with interpreting the prescription
• incorrect drug strength or concentration
• incorrect duration of treatment
• prescription of meds that are inappropriate for a patient because of other meds or other contraindications
• errors made in inputting data into a pharmacy database
• mixups between drugs names that sound similar, such as Losec and Lasix
• errors made during the filling of the prescription, such as dispensing too few pills or mixing up the bottles of two prescriptions

Most of the mistakes were easily rectified, usually with a phone call to the prescribing physician to clarify a problem. But other problems are more systemic.

In Mahone Bay, pharmacist Susan Beresford found that errors were more likely to be made on certain days.

"What we found is Mondays from lunch time to about 5 p.m. was the time that we had these near hits," she says, "These were things that didn't leave the dispensary but this was the time that we needed to be more focused."

To correct the problem, her pharmacy added staff during busy periods, and made additional checks on prescription accuracy.

"We were able to decrease the chance of a near hit by 36 per cent in the first four months," she reports.

MacKinnon says what is key about the SafetyNET program is that it is anonymous and non-punitive, which should help the health professionals involved feel comfortable in reporting errors.

"We are trying to take away the fear of reporting. In the past in health care, health professionals have been afraid to report errors. They are often afraid of lawsuits and losing their jobs," he says.

"With SafetyNET, we are encouraging reporting within a safe environment so our pharmacists know they will not be penalized."

The ultimate goal is to allow different kinds of pharmacies to learn from each other about what kind of errors are being made, why, and what can be done to prevent them.

"SafetyNET helps us do a much better job and best of all, share that with other pharmacists locally and nationally and take away the stigma of near-hits so that we are able to discuss what happened and hopefully prevent it from happening in the future," says Beresford.

MacKinnon says the goal now is to finish collecting all the data from the 12-month project, and then expand the SafetyNET program across Nova Scotia and across Canada.

With a report from CTV medical specialist Avis Favaro and producer Elizabeth St. Philip