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Don Lavoie is alcohol programme manager at Public Health England and Gul Root is lead pharmacist, Health and Wellbeing Directorate, Public Health England
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RPS logoJuly 29 2015

Two new tools to help identify, record and review ‘near miss’ errors (NMEs) are available for Royal Pharmaceutical Society members. NMEs are errors that have happened but have been identified and corrected before reaching the patient.

The Near Miss Error Log can be used to record neat miss errors and the circumstances in which the error occurred. It comprises a table to record factors such as time of day, staffing levels, staff involved, product name, type of near miss error, possible causes, as well as aspects to consider such as product specific requirements and what action has been or can be taken.

The second tool is a Near Miss Error Improvement Tool which can be used to analyse and review the information that has been recorded in the log. It should help identify any trends and contributing factors so that an action plan can be drawn up to help reduce the risks of similar near miss errors occurring again, says the Society.

“Regular review of NMEs and action taken can prevent similar mistakes from happening in the future. The Society has produced this guidance to help support clinical governance in pharmacy, and to promote an open culture of recording of NMEs so that all pharmacy staff can reflect and learn from them”

The RPS points out that the guidance “does not cover dealing with errors that have reached a patient that may or may not have caused harm to a patient. It does not replace any standard operating procedures you may have in place for dealing with errors.”

Among the tips for using the NME Log is to appoint a lead or champion for NMEs who will regularly encourage everyone to record any NMEs every day, and to have a team discussion to raise awareness of the potential consequences and adverse effects should the error actually have reached the patient.

The NEM Improvement tool also encourages all the staff to discuss the NME, and to make NME review a continuous, cyclical process to promote continuing learning. Also included with the tools is a list of useful resources with web links.

Links:

RPS announcement    

RPS Near Miss Errors Tools    

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