ISQUA17-1596PREVENTION OF WRONG MEDICATION THROUGH ENHANCED CLARIFICATION BY PHARMACIST ON QUESTIONABLE PRESCRIPTION

Abstract

Objectives: Medication safety in community pharmacy have been increasingly focused in Japan as community pharmacy routinely handles with prescription of such high risk drugs as anticoagulation drug, anti-tumor drug and so on. Nationwide pharmaceutical near-miss reporting and learning system has been operated by the Japan Council for Quality Health Care (JQ) since 2009 aiming at enhancing medication safety in community pharmacy. Near-misses reported in 2015 were put on analysis for creating preventive knowledge. Methods: Near-miss which occurred or was identified in community pharmacy is routinely collected from registered community pharmacy on voluntary basis in the reporting system. JQ collects, tabulates data of those events and compiles annual report and monthly case report. On observation of the reports, several focused areas are identified and put on further analysis to withdraw lessons for prevention. Results: The pharmaceutical near-miss reporting system collected 4,779 near-misses in 2015. The breakdown of collected near-misses revealed that 78.0% near-misses (3,727 cases) are those related to dispensing such as wrong quantity, wrong strength, wrong form of drug and so on. What was most highlighted was that increasing number of cases were related to clarification by pharmacist on questionable prescription issued by hospital/clinic. The government policy on medication to patients has been that prescription and dispensing are separately allocated to hospital/clinic and community pharmacy. Clarification on questionable prescription was stipulated in “Article 24 of Pharmacist Law” as a vital role of pharmacist. The near-miss related to clarification accounts for 21.8% (1,040 cases) of reported cases. It was revealed that patients' health conditions were possibly affected if dispensed along with original prescription in 64.6% (672 cases) near-misses among 1,040 near-misses related to clarification. Therefore, near-misses related to clarification were focused and put on in-depth analysis in terms of background human factors, the way to identify error on prescription, brand names of drug and so on. As a result, prescribed drugs are frequently deleted (26.0%, 270 cases) and/or replaced with correct drugs (34.8%, 362 cases) by adequate clarification which was triggered by identifying duplication of drugs on prescription sheet or inconsistency of latest prescription with past prescription records of individual patients filed in a pharmacy. Specifically, such drugs as anti-ulcer drugs and analgesics are frequently reported. Near-misses with failed clarification were later found questionable on the following reasons. i) Pharmacist reviewed dispensing record., ii) Family gave pharmacist question on the medication., iii) Patient visited pharmacy for the next dispensing. Therefore, it was suggested that confirmation of patient's name, current health condition, past side effect, patient's age and confirmation of pregnancy are effective for prevention. (Figure Presented) Conclusion: The nationwide pharmaceutical near-miss reporting system is now widely welcomed and utilized in Japanese pharmaceutical society, medical society and relevant societies. It is successful in a sense that it has been offering scientific data of near-misses such as those related on inquiry on questionable prescription.