Community pharmacists and general practitioners are being encouraged to take part in a pilot programme designed to find out more about medication errors and how to prevent them.
The Medication Error Reporting and Prevention pilot is funded by the Ministry of Health and is being run by the national pharmacovigilance centre at the University of Otago.
During the pilot, which will end in May, about 40 pharmacists and a similar number of GPs will anonymously use a secure web-based reporting system to report medication errors and near misses.
One of the investigators, centre director Dr Michael Tatley, emphasised the purpose of the pilot was not to apportion blame over any of these events, but to establish what happened and see what could be learned from that.
Those participating would be asked for details about what happened, what led to it, how the situation was handled, how the error might be prevented and what actions might have been taken to prevent future errors.
The programme was not designed to intervene in an event.
By the time a wrong dose, wrong drug or other matter was reported, the actual event would have been dealt with and that needed to happen as part of pharmacists' and GPs' "own local protocols", he said.
Information identifying patients or the health professionals participating would not be submitted.
Medications covered under the pilot included prescription, pharmacy-only medicines, those bought over the counter, vaccines, complementary and herbal medicines. Blood products would not be included.
Internationally, medicine errors had been identified as the leading cause of harm to hospital patients and there had been increasing attention to programmes to report and prevent errors in that setting. However, less was known about the situation in the community and how big the problem was, Dr Tatley said.
There was some information from organisations such as ACC and the National Poisons Centre through patient safety incident reporting systems. During the pilot, anonymised information from them would also be collated.
Co-investigator Dr Desiree Kunac carried out a review of 1412 spontaneous reports made to the Centre for Adverse Reactions Monitoring during 2007, which showed about 4% of events reported that year could have been prevented.
About two-thirds of these were associated with some degree of patient harm and included such errors as incorrect dose, drug interactions and lack of necessary clinical monitoring.
About 80% of the 61 errors identified were deemed to have originated in the community setting.
In the long term, the hope was that the system being tested in the pilot would be used to establish a national database of medication errors originating in the community. Such a system could then be used to help develop any needed preventive measures.
Dr Tatley said the investigators did not want to burden busy health professionals and it was hoped the reports would take between five and 10 minutes to complete.
He was hopeful there would be enough events recorded before the pilot's end to provide "meaningful results". These would demonstrate how useful the system was and how well it worked.
He was pleased to note general practitioners and pharmacists were already showing interest in taking part in the pilot.
