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Published on 26 July 2007

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Risk management and the hospital pharmacist

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The essence of risk management is to anticipate potential risks and take action before incidents occur. The hospital pharmacy manager is responsible both for managing the risks posed to patients by the use of medicines (and accompanying information) and the risks to hospital and pharmacy staff which arise from handling medicines. This warrants a good understanding of the risks inherent in all hospital activities. Understanding can come partly from theoretical knowledge and partly from local incident logs or error reports. The attitude that “we have not seen that problem so it will probably not occur here in the future” is completely incompatible with competent risk management. An organisation with a good risk management culture will carry out routine risk assessments on new products or procedures and will record incidents if they occur. As has been amply demonstrated by the aerospace industry, the recording of near-misses, as well as actual incidents, provides vital information. One useful way to approach risk assessment is through “failure mode and effects analysis”. This involves asking, “what could go wrong and how serious would the consequences be?” The next step is to work out how such consequences could be avoided or minimised.

Medicine supply is associated with a number of well-recognised risks. A prescriber’s poor handwriting or human error in the pharmacy may result in incorrect medicine supply. Other errors, such as incorrect strength or formulation, are also common. When errors occur, it is important to examine the system that led to them taking place. Sometimes medicine labelling is so similar that it can cause confusion but on other occasions cramped or dimly lit storage conditions may make accurate selection difficult. Computerised prescribing systems can eliminate errors arising from poor handwriting and well-designed, automated dispensing systems can reduce incorrect selection.

The hospital pharmacy manager’s responsibility extends beyond the pharmacy door and encompasses the packaging and labelling of medicines as well. For example, incorrect doses are often administered by injection because the strength



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