Imagine a system where a simple mistake could mean life or death. That's the reality pharmacists face every single day. A recent audit reveals a shocking truth: pharmacists are catching a staggering number of prescription errors – over 1200 in just one week! But here's the truly frightening part: more than a quarter of these errors could have caused serious harm to patients.
This eye-opening audit, conducted across 68 pharmacies in New Zealand's Midland Region (including areas like Waikato, Bay of Plenty and Taranaki), sheds light on a critical, often unseen, problem within our healthcare system. Using a custom-built app powered by AI, pharmacists meticulously tracked and reported prescription issues as part of the Script Audit, the first exploration of electronic scripts in New Zealand.
The audit was spurred, in part, by the tragic death of a two-month-old baby in Manawatū earlier this year due to a medication overdose. Midland Community Pharmacy Group chief executive Pete Chandler, who spearheaded the audit, explained this tragedy amplified existing concerns among pharmacists about systemic clinical risks. "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."
So, what kind of errors are we talking about? The most frequent issues involve incorrect dosages (accounting for 25.93% of all errors – for example, a recent case highlighted a woman overdosing on fentanyl after a pharmacy dispensed six times the prescribed amount!), followed by incorrect quantities, missing information, and prescriptions for inappropriate medications that could clash with other drugs a patient is taking. And this is the part most people miss: pharmacists aren't just handing out pills; they're often the last line of defense against potentially devastating mistakes.
But here's where it gets controversial... While the audit highlights a significant problem, it also reveals a wide variation in the rate of "interventions" – the frequency with which pharmacists identify and correct errors. Some pharmacies reported issues in less than 1% of scripts, while others found problems in over 11%! Does this mean some pharmacies are simply more diligent in their checks? The report suggests so, noting that pharmacies with higher intervention rates were known for their "highly competent and thorough clinical checking." This raises a crucial question: are we adequately recognizing and rewarding pharmacies that prioritize patient safety?
The audit found that pharmacists spent a total of 347 hours resolving these prescription problems, with an average resolution time of just under 19 minutes per issue. Think about that: nearly 20 minutes spent tracking down prescribers, clarifying details, and ensuring patient safety – time that could be spent providing other essential services.
Chandler emphasizes the frustration and inefficiency this creates. Pharmacists often have to chase down junior doctors who are no longer on shift or navigate busy GP offices. Even seemingly minor issues, like unscannable barcodes or missing patient details, consume valuable time. "There are a range of issues that can happen, but this is time that we really need to use for something else."
A previous survey by the Pharmaceutical Society further underscores the scale of the problem, revealing that 45% of pharmacists make up to five clinical interventions every day, and 6% make as many as 40! As North Shore pharmacist Michael Hammond, president of the Pharmaceutical Society, points out, this "unseen activity" is not adequately recognized or funded.
Electronic prescribing, while intended to improve accuracy, has inadvertently introduced new challenges. The audit points to IT system flaws as a significant contributor to script issues, increasing workload and risk for both pharmacists and prescribers. As Chandler puts it, "Often what the GP thinks they've asked for is not what the pharmacist sees."
Dr. Prabani Wood, medical director of the College of General Practitioners, acknowledges that existing software systems are not entirely fit-for-purpose, lacking the "fail-safe mechanisms" to prevent serious errors. She also highlights the difficulty for GPs to stay up-to-date with constantly changing medication funding and supply issues.
The report concludes that a coordinated effort is needed to address the root causes of these problems, rather than relying on workarounds. This requires collaboration at the national, regional, and local levels, including working with IT providers to improve their systems.
The key takeaway? The current system is placing an unsustainable burden on pharmacists, who are acting as a crucial safety net without adequate resources or recognition. As the report starkly states, "Doing nothing is no longer a defensible option."
What are your thoughts on this issue? Do you believe pharmacists are adequately supported in their role as patient safety guardians? Should there be more investment in improving electronic prescribing systems? Share your opinions and experiences in the comments below!
