Reporting, Review and Application of Near‐Miss Prescribing Medication Incident Data

Abstract

Prospective drug chart review by pharmacists is an important risk minimisation strategy in the detection and prevention of prescribing medication incidents (PMis). Feedback reporting to the clinical team facilitates learning from and the identification and prevention of system-based PMis. At Westmead Hospital, Sydney, the establishment of a relational database ofprevented-PMis in November 2001 enabled such feedback reporting. Assessment of the reporting process after 12 months indicated review and application of the data within quality frameworks, value in improving prescribing practice and continued interest in receiving the reports. Implementation of feedback reporting has facilitated learning from PMis beyond the prescriber to the team and organisational levels. PMI data have been incorporated into 'safe prescribing' training programs for junior doctors. The proactive role of the clinical pharmacist in ensuring safe medication outcomes has been highlighted. Establishment of data management and reporting processes may assist future incorporation into wider incident-monitoring systems.

Medication safety in acute care in Australia: where are we now? Part 2: a review of strategies and activities for improving medication safety 2002-2008

“…A study conducted at a NSW tertiary hospital examined a systems-based approach to reporting, review and feedback of data obtained on prescribing incidents in the hospital [ 69 ]. A database of prevented prescribing incidents (near-miss incidents) detected by hospital pharmacists was developed.…”

Feedback to doctors about prescribing errors in the hospital setting

“…Prescribing errors are the most common type of avoidable medication error [3]; it is known that pharmacists play an important role in medication error prevention, with the associated potential cost-benefit implications [4].…”