Empowering you to meet regulatory and best practice requirements

A message from Claire Nevinson, Superintendent Pharmacist

I hope 2025 brings all of you good health and happiness. No doubt many of you will, like me, be making New Year’s resolutions that will hopefully last beyond the end of the    month! To start 2025 we want to offer you two patient safety new year’s resolutions called ‘Always Events’ and ‘Never Events’ which will help towards the elimination of errors that occur during dispensing and handout. The introduction of ‘Always Events’ and ‘Never Events’ focuses on two specific parts of dispensing, where we know that by meticulously sticking to the process steps described in the SOPs we can prevent incidents. At the same, we equally know ‘human factors’ mean it’s easy to divert from the process and for an error to occur. 

Always Events: ALWAYS follow ‘single item flow’ principles when dispensing using Assisted Due Date Dispensing (ADDD) or Scan to Accuracy Check. The introduction of these new systems improves dispensing accuracy, by using barcode scanning technology for verification. To make sure that this benefit is realised, it’s important to recognise that the dispensing process is quite different from traditional ‘batch’ process dispensing. When using these systems, you should ALWAYS follow these principles: 1. Dispense one item at a time; 2. Have nothing else on the surface of the workstation; 3. Follow pop-up messages carefully. 

Never Events: NEVER hand someone the wrong person’s medication. Handing someone the wrong person’s medication is another error which can be prevented in part by using barcode scanning technology, but where human factors like distraction and multi-tasking can result in process steps being missed or incorrectly followed. Here there are also three principles: 1. Check: Ask for the patient’s details, enter into Columbus and confirm back; 2. Scan every bag; 3. Double check: Look at the bag label(s) and ask the patient for their ID details again, plus postcode. 

We are introducing a new Manager’s Observation Tool for Always Events and Never Events to help spot when processes aren’t being followed in line with the above principles. What’s really important to remember is that this is not a test that you can pass or fail. Real success is where a team member is found to be unintentionally not following a process, and that this is captured and learned from. Only by being open and transparent in this way, just as we are with near misses and incidents, will we learn and so prevent more incidents. Pharmacists are asked to not add a newly trained team member on to the Responsible Pharmacist Task & Role Matrix to carry out an activity unsupervised until the team member has been observed to be following the relevant SOP consistently. I hope you will join me in adopting ‘Always Events’ and ‘Never Events’ and make these New Year’s resolutions on behalf of our patients.