Student observations of medication error reporting practices in community pharmacy settings

Abstract

Background: Medication safety practices and methods for reporting errors in community pharmacies are relatively unknown.

Objective: (s): The primary objective of this study was to describe student-reported data on medication safety and error reporting practices in community pharmacies, and secondarily describe student learning from this assignment.

Methods: Second professional year pharmacy students enrolled at Purdue University College of Pharmacy in the United States observed and recorded medication safety and error reporting practices as part of an experiential assignment. Data were collected from 170 unique pharmacy settings between the years 2016-2018 and analyzed using descriptive statistics and a paired t-test to assess student learning.

Results: 51% of students reported documentation of 1-10 errors or near misses annually, with an additional 30% reporting 11-30. Near misses were only reported 26% of the time. Errors were most commonly reported to a pharmacy-specific reporting system (84%) and the Institute for Safe Medication Practices National Medication Errors Reporting Program (84%). The most frequently reported error types included wrong directions (34%), wrong drug (14%), wrong strength (13%), and wrong patient (12%). Pharmacists were observed to be interrupted approximately 19 times every hour. Anonymous error reporting was typically not allowed to the pharmacy's preferred error reporting system (71%). A policy requiring that the prescriber is contacted about errors was observed at 77% of the sites. The most common consequences of committing an error were education/training (72%) or progressive discipline (41%). Students reported a statistically significant increase in understanding of medication safety practices and methods for reporting errors in community pharmacies. (p < 0.01).

Conclusion: This data supplements existing literature on medication safety practices and error reporting in community pharmacy settings, as well as highlights knowledge gaps outside the scope of this study.

Keywords: Community pharmacy; Medication error reporting; Medication safety.