Pharmacists in Manawatū and Bay of Plenty uncovered a startling number of prescription errors in just one week, highlighting the critical role they play in patient safety. A week-long audit revealed 1,257 issues in prescriptions, with 1,145 reports identifying 1,247 problems. The most common issues were dose-related (25.93%), followed by quantity discrepancies, missing details, and inappropriate medications. Alarmingly, 26% of these issues posed a high risk of harm to patients, prompting pharmacists to spend a total of 347 hours resolving them. The mean resolution time was just under 19 minutes, showcasing the dedication and efficiency of these professionals.
The audit, involving 68 pharmacies, was the first of its kind in New Zealand, utilizing a custom-built reporting app. The initiative was sparked by the tragic death of a two-month-old baby in Manawatū, who overdosed due to a pharmacy error. This incident, along with long-standing concerns about system-wide clinical risk, prompted pharmacists to take action. The audit's findings underscore the importance of pharmacists as the primary safeguard against electronic script deficiencies and other prescribing issues.
However, the report also revealed a concerning trend: pharmacists are shouldering the burden of addressing these issues without adequate resources or recognition. The Pharmaceutical Society's survey of 20 pharmacists found that 45% made up to five clinical interventions daily, while 6% handled up to 40. This hidden workload is a significant concern, as it diverts time and effort from other critical tasks. The report emphasizes the need for better communication between general practice and pharmacy, as well as improved IT systems to reduce errors and streamline processes.
Despite the challenges, there are promising micro-improvements on the horizon. One GP practice introduced a dedicated text-only line for pharmacy prescription inquiries, demonstrating a willingness to address root causes. However, systemic improvement requires collaboration at various levels, including national, regional, and local pharmacy and general practice settings, as well as working closely with IT providers to enhance their systems. The audit's findings serve as a stark reminder that inaction is no longer an option, and the time has come for comprehensive reform to ensure patient safety and reduce the burden on pharmacists.
