L11.Quality Assurance

Quality Assurance in Pharmacy

  • Importance of Quality Assurance

  • Addresses the reality that medication errors can and do occur in pharmacy practice.

  • A philosophy aimed at improving safety and procedures associated with medication dispensing.

  • Immediate Actions on Medication Errors

  • Notify the Pharmacist:

    • Essential first step when an error occurs.

    • Must not be ignored or understated due to the potential for harm.

  • Investigation:

    • The pharmacist assesses the problem's severity and cause.

    • Communication with involved providers or nurses to address the issue.

    • If the error is noticed pre-administration, it can often be resolved internally.

    • If the medication has been given to the patient, corrective action will depend on the situation.

    • Patient safety is the first priority in any corrective action.

  • Documentation of Errors:

  • A Medication Error Report Form must be completed accurately.

  • Reports are sent to:

    • Risk management department

    • Quality assurance committee

    • Legal department if necessary.

  • Parent/Guardian Notification:

  • Parents must be informed of any medication errors immediately.

  • Encourage parents to report any errors back to the child’s healthcare provider.

Types of Medication Errors

  • Common Medication Errors:

    • Incorrect child

    • Incorrect medication

    • Incorrect dosing times (too early or too late)

    • Incorrect dose

    • Incorrect route of administration

    • Administration of expired medication

    • Missed doses

    • Consent expired

    • Other.

  • Completing the Report:

    • Include details from the child’s authorized consent form

    • Medication name authorized

    • Dosage and administration route authorized

    • Frequency of administration and signs that necessitate medication.

Analyzing Trends in Medication Errors

  • Review of Medication Error Reports:

  • Quality assurance committees regularly review reports to identify trends and patterns in errors.

  • Implementation of Changes:

  • Upon identifying a trend, root causes are analyzed.

  • Changes are then implemented to address the issues directly leading to errors.

  • Monitoring and Evaluation:

  • The effectiveness of changes is monitored to ensure improvement in practices.

  • Example: If training shortcomings lead to errors, revamping training programs would be warranted.

Final Thoughts

  • Quality Assurance as Philosophy and Process

  • Reflects the understanding that while errors will occur, proactive quality assurance initiatives can lead to improvements in patient safety.