Imagine that a medication error has occurred in your pharmacy – for example, the wrong medicine being handed out

You investigate the incident and find that a member of staff got confused between two types of medicine. It seems that the staff member doesn’t know medicines that well. So there’s the answer – to have that staff member do some learning about the medicines. Or is it?

A look at the shelving identifies another problem: the two items that were mixed up, which happen to be look-a-like-sound-a-likes, were kept next to each other without anybody realising the hazard this created. So maybe the answer is actually to sort out the shelving.

But wait – it turned out that there was another problem, in that the checking procedure was not followed, and had it been then the mix up between the medication types would have been detected before it was handed out. Why was that? It seems that staff members had got into the habit of not following the SOP on checking. So maybe they need to be reminded what the SOP says? 

When this matter is taken up with the staff though, they point out that at some points of the day they have so much to do that they don’t feel they can spare the time to follow the SOP. Usually this is not a problem, because there is usually an experienced dispenser on hand to oversee the item picking, but this time, they were caught out.

And, as it turns out, it is the same time pressure that makes staff feel unable to stop and think when they are either taking items off the shelf or putting items onto the shelf.

So, given all this, what do you think is the cause of the incident?