Error Management Reflection

Error Management
Error Management

Error Management

Types of prescriptions, roles of intra and interprofessional teams, and medicine storage and disposal

            This error management reflection covers what I have learnt from the hospital placement by considering Borton’s model. Specifically, I have explored the error reporting process in the hospital and how it has helped me to understand the principles of clinical governance. Furthermore, this error management reflection describes the difference in error reporting processes in community pharmacy compared to hospital pharmacy.

During my placement, I have discovered that the main types of prescriptions in the pharmacy are outpatient prescriptions, cleansing preparation prescriptions, and ward order prescriptions. The pharmacy rarely uses hospital charts and it does not use TPN requests at all. Furthermore, I have learnt that the pharmacy team members perform roles, which are complementary to one another.

For instance, the pharmacist checks medicine history, the technician reviews medicine history and dispenses drugs, and ATO checks stock of drugs and delivers medicines to the wards. Again the pharmacy has well documented standard operating procedures related to storage and disposal of medicines. In the pharmacy, drugs are stored in shelves and they are categorized based on their functions. Moreover, medicines must be checked and reviewed before they are disposed.

Error management: How error reporting improves clinical governance

            Error reporting plays a significant role in improving clinical governance. According to Freedman (2006), NHS institutions rely on clinical governance to deliver quality care to patients by allowing parents to get involved in their treatment process. Since the patient is the first priority in clinical governance, there is always great need for hospitals to ensure that their error reporting systems are working well in order to improve clinical governance.

Medication errors are avoidable mistakes that are made by health care practitioners during prescription, dispensation, and administration of drugs. Such errors negatively impact on patient safety and outcomes. As MRA (2014) explains, error reporting is one of the ways through which health care practitioners learn their mistakes and it therefore plays a big role in improving patient safety.

During my placement, I have discovered that the main source of medication errors in the facility is incorrect drug labelling, and that error reporting greatly improves clinical governance. Specifically, I have discovered that the hospital has a stable system for detecting and reporting medication errors. In addition, I have learnt that, since it is possible to detect medication errors, the facility should have a plan of how such errors can be prevented.

According to Polnariev (2016), through error reporting, healthcare organizations can easily identify and mitigate risks early enough. Therefore, the facility should employ appropriate measures to prevent recurrence of medication errors in future in order to improve clinical governance.

Difference in error reporting in community and hospital pharmacies

            Error reporting in community pharmacy differs significantly from that of a hospital. During my placement, I have been able to identify two major differences in error reporting between a community pharmacy and a hospital pharmacy during my placement. First, while delegated authorities are charged with the responsibility of overseeing medication errors in the hospital, the board of directors is directly involved in error reporting process in the community pharmacy (Brunsveld-Reinders, Arbous, Vos, and Jonge, 2016).

Second, community pharmacy mainly relies on voluntary reporting while hospital pharmacy utilizes voluntary, confidential, non-confidential, and mandatory reporting processes. Voluntary reporting process that is mainly used by community pharmacy is not very effective because it leaves some errors unreported. However, mandatory reporting by hospitals ensures maximum error reporting and it helps healthcare practitioners to avoid lawsuit.

In this regard, community pharmacies should use mandatory reporting instead of voluntary reporting in order to improve error reporting (Brunsveld-Reinders et al., 2016).

            In conclusion, the most enjoyable parts of my placement were getting to learn the role played by error reporting in clinical governance, and the difference between error reporting process in a community pharmacy and a hospital pharmacy. Through error reporting, hospitals can greatly maximize patient safety and improve their health outcomes.

Unfortunately, effective identification of errors cannot be achieved because some errors go unreported. In order to prevent recurrence of medication errors in future, health care organizations should introduce strict measures of reporting such incidents. However, the least enjoyable part of my placement was retrieving information related to medication errors and error reporting process from employees at the pharmacy.

In order to facilitate easy interaction between the student and the hospital’s workers in future, learners should be allowed to choose facilities which they feel would be comfortable for them to undertake the placement.

Reference List

Brunsveld-Reinders, A. H., Arbous, M. S., Vos, R. V. & Jonge, E. D. (2016). Incident and error reporting systems in intensive care: a systematic review of the literature. International Journal for Quality in Health Care28(1), 2-13.

Freedman, D. B. (2006). Involvement of patients in clinical governance. Clinical Chemistry and Laboratory Medicine, 44(6): 699-703.

MHRA. (2014). Patient Safety Alert.  Retrieved from

Polnariev, A. (2016). Using the medication error prioritization system to improve patient safety. Pharmacy and Therapeutics, 41(1): 54-59.

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