Practice audit results in 100% fewer medication errors

Rosemullion Veterinary Practice quality improvement project significantly reduces prescribing and dispensing errors and near misses

A clinical audit, conducted by Rosemullion small animal practice in Cornwall, has resulted in 100% fewer errors and 52% fewer near misses when prescribing and dispensing medicines.

The three-site small animal practice, with 100 members of staff, dispenses 3,584 medications in an average month. A new audit set out to identify any patterns in errors and near misses surrounding the prescribing and dispensing of this medication, in order to make improvements in practice, processes and systems. 

Medication errors account for 30% of all reported errors in veterinary practice^[1]. 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. These errors can have wide-reaching impacts on the patient, owner and veterinary colleagues.

An initial clinical audit was conducted between 1 March 2023 to 31 May 2023, looking at entries on Rosemullion’s VetSafe system. 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 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. 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 – were 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. 

In addition, a CPD session was held with the practice team to highlight the common errors that were occurring, to explain resulting process and systems improvements, and ask them to take extra care with these dispensaries.

As a result of constructive discussions, 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 1 October 2023 to 31 November 2023. Here, 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:

Rosemullion Veterinary Practice’s initiative has recently been recognised with a RCVS Knowledge Highly Commended status at its 2024 awards.

^{[1] Why do medication errors occur in veterinary practice. Mosdale & Blackie. Companion Animal, Jul-August 2021. Vol 26, No7.}