Error recovery in a hospital pharmacy

Abstract

A field study was performed in a hospital pharmacy aimed at identifying positive and negative influences on the process of detection of and further recovery from initial errors or other failures, thus avoiding negative consequences. Confidential reports and follow-up interviews provided data on 31 near-miss incidents involving such recovery processes. Analysis revealed that organizational culture with regard to following procedures needed reinforcement, that some procedures could be improved, that building in extra checks was worthwhile and that supporting unplanned recovery was essential for problems not covered by procedures. Guidance is given on how performance in recovery could be measured. A case is made for supporting recovery as an addition to prevention-based safety methods.

Keywords:

• Error recovery
• Near misses
• Incident analysis
• Medication error
• Patient safety
• Hospital pharmacy

Acknowledgements

The cooperation of the hospital pharmacy that welcomed our research and the participation of the pharmacy's employees in our studies have been essential and are greatly appreciated.