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Rosemullion Veterinary Practice is a three-site small animal practice owned by CVS.
It has 100 members of staff and dispenses 3,584 medications in an average month.
According to an article in Companion Animal, medication errors account for 30% of all reported errors in veterinary practice1.
Errors can be prescribing errors - where the vet prescribes the incorrect medication or dosage, or dispensing errors where the incorrect medication, strength or volume is dispensed by the pharmacy team.
Some errors can ‘look or sound alike’ – where medications have similar names or packaging – making them easy to mix up.
Rosemullion conducted an initial clinical audit of entries on its VetSafe system between 1st March and 31st May 2023.
Analysis was conducted on the drugs involved, whether they were prescribing or dispensing errors or near misses, and looking for patterns of behaviour or the drugs involved.
During this time there were 29 (0.27%) near misses and 14 (0.13%) errors.
Prescribing near misses most often involved flea and worm products.
Here additional feedback from vets was that it was difficult to remember weight brackets for all products and when weight brackets were included in the drug description this made them easier to prescribe accurately.
As a consequence, the Rosemullion pharmacy team introduced the inclusion of weight brackets on all flea and worm products.
Dispensing errors and near misses were mostly related to ‘look or sound alike’, particularly in worming tablets, flea treatments and Rheumocam cat and dog.
To address this, the Rosemullion pharmacy team added extra labelling to dispensary draws and separated draws for flea and worm treatments into different weight brackets.
Rheumocam – with its similar packaging design and box sizes – was also split into separate cat and dog drawers, and drawers clearly labelled up with the version and volume to make dispensing clearer.
Feedback was also given to the drug manufacturer.
Rosemullion also held a CPD session to highlight the common errors that were occurring, to explain resulting process and systems improvements, and ask the team to take extra care with these dispensaries.
A new ‘handing out medication’ process was also created – involving checking the medication in the bag matched the on the screen notes, confirming it was for the correct animal and validating it was what the owner was expecting.
A subsequent audit was run from 1st October to 31st November 2023.
The results revealed there were no prescribing or dispensing errors (0%) and only 8 (0.13%) near misses during this time.
Alice Bell, Senior Vet and Quality Improvement Lead at Rosemullion Veterinary Practice, said: “We place patient safety at the forefront of all we do.
"We wanted to conduct this extensive audit to assess our prescribing and dispensing processes and systems.
“The methods we had in place made it easy to do the task correctly and the changes we have now put in place have made the process even safer for our clients.
"Our overall error and near miss is now at a really low number compared to our total number of medication dispenses.
“The teams have been very receptive to the improvements and the project has had a positive impact on various aspects of the practice, including on team wellbeing.”
Rosemullion Veterinary Practice’s initiative has recently been recognised with a RCVS Knowledge Highly Commended status at its 2024 awards.
Reference
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