A pharmacist was experiencing issues with implementing a quality improvement initiative to address an increased frequency of near miss medicine errors.

To improve quality, the pharmacist decided to retrain dispensary staff with regards to the dispensing process. The error rate did not significantly reduce, and this posed safety risks for patients. 

With knowledge of quality improvement, the pharmacist engaged the help of all staff to establish the root cause of the near misses. At the outset, the pharmacist explained the impact to patient safety and process quality. She engaged the staff to identify the core problem contributing to the errors. Through this process of engagement, employees identified that LASA (look alike, sound alike) errors were the main problem. 

Working collaboratively as a team, some prevention strategies were proposed for testing. These included simple steps such as storing products in separate areas and displaying alerts on the products and in storage. It was agreed to use the PDSA cycle to test these small changes.

As a result of engaging staff at the frontline, near miss errors greatly reduced. The pharmacist communicated the results with all staff. As a result, staff felt more involved and empowered with the improvement process and this encouraged more ideas to reduce the potential for LASA errors.