1 00:00:00,120 --> 00:00:02,480 Speaker 1: Now, you might recall the heartbreaking case of the baby 2 00:00:02,480 --> 00:00:04,960 Speaker 1: who died from a medication overdose earlier this year. We 3 00:00:05,000 --> 00:00:07,760 Speaker 1: talked about it on the show. After that tragedy, the 4 00:00:07,800 --> 00:00:10,959 Speaker 1: Midland Community Pharmacy Group decided to review just how often 5 00:00:11,000 --> 00:00:15,400 Speaker 1: prescription eras happen. The findings are staggering, more than one thousand, 6 00:00:15,680 --> 00:00:18,400 Speaker 1: two hundred mistakes in a single week, and a quarter 7 00:00:18,480 --> 00:00:20,920 Speaker 1: of them carried a high risk of harm. Pete Chandler 8 00:00:21,000 --> 00:00:23,800 Speaker 1: is the CEO of the Midland Community Pharmacy Group. 9 00:00:23,600 --> 00:00:27,360 Speaker 2: And with us high Pete, Hi, Heather, did this surprise you? 10 00:00:29,160 --> 00:00:33,920 Speaker 3: It did surprise me very so seeing these reports flag 11 00:00:34,000 --> 00:00:36,239 Speaker 3: up on my laptop every few minutes from when we 12 00:00:36,280 --> 00:00:37,120 Speaker 3: started the audit. 13 00:00:37,600 --> 00:00:39,400 Speaker 2: Oh wow, were you getting in real time? 14 00:00:40,200 --> 00:00:40,440 Speaker 3: Yeap? 15 00:00:41,080 --> 00:00:42,840 Speaker 2: And so were you sitting there watching it come in? 16 00:00:43,680 --> 00:00:44,880 Speaker 3: I was yeah? 17 00:00:45,000 --> 00:00:48,879 Speaker 1: And what was the feeling was was your heart just sinking? 18 00:00:50,640 --> 00:00:53,680 Speaker 3: I think there are two things that I saw as 19 00:00:53,760 --> 00:00:57,520 Speaker 3: one is the frequency of issues being reported, but also 20 00:00:57,600 --> 00:01:00,800 Speaker 3: the narrative text that pharmacists wrote a lot side that 21 00:01:00,960 --> 00:01:04,520 Speaker 3: explained the nature of repeating issues and so yeah, your 22 00:01:04,520 --> 00:01:07,480 Speaker 3: heart does think thinking we really do have a problem. 23 00:01:07,720 --> 00:01:11,360 Speaker 1: Yeah, Okay, Now I feel like in the interest of 24 00:01:11,440 --> 00:01:14,399 Speaker 1: being fear it is not just pharmacists who are responsible 25 00:01:14,400 --> 00:01:17,040 Speaker 1: for these twelve hundred mistakes, right, it's the doctors as well. 26 00:01:17,640 --> 00:01:21,920 Speaker 3: Correct, But I need to clarify that what we've audited here, Heather, 27 00:01:22,560 --> 00:01:28,520 Speaker 3: is a subset of issues that pharmacists have picked up 28 00:01:28,520 --> 00:01:32,759 Speaker 3: with prescriptions rather than clinical errors. And there's a really 29 00:01:32,760 --> 00:01:39,160 Speaker 3: important difference in that we weren't auditing patient medical records 30 00:01:39,200 --> 00:01:43,480 Speaker 3: to find prescriber errors. We were capturing issues that pharmacists 31 00:01:43,480 --> 00:01:47,680 Speaker 3: spotted on scripts that needed time to resolve. So that's 32 00:01:47,720 --> 00:01:49,200 Speaker 3: a really important distinction. 33 00:01:49,480 --> 00:01:51,920 Speaker 1: Oh, okay, hold on, not on, So we are not 34 00:01:52,080 --> 00:01:56,160 Speaker 1: this is not mistakes pharmacists are making. These are mistakes 35 00:01:56,200 --> 00:01:58,480 Speaker 1: doctors are making that pharmacists are picking up. 36 00:02:00,120 --> 00:02:04,680 Speaker 3: Five Further, they're not necessarily mistakes, but they are issues. 37 00:02:05,240 --> 00:02:08,600 Speaker 3: So the distinction we've made here is that an issue 38 00:02:08,840 --> 00:02:12,200 Speaker 3: is not necessarily an error, but it is a problem. 39 00:02:12,639 --> 00:02:15,120 Speaker 3: And a lot of these issues do relate to the 40 00:02:15,200 --> 00:02:19,680 Speaker 3: functioning of IT systems rather than actual clinical errors. So 41 00:02:19,720 --> 00:02:21,840 Speaker 3: it's important to be really clear on that, and that 42 00:02:22,000 --> 00:02:25,920 Speaker 3: was the reason why we did this audit to understand 43 00:02:25,960 --> 00:02:28,680 Speaker 3: the extent of things that pharmacists were having to work 44 00:02:28,680 --> 00:02:29,960 Speaker 3: with GPS to resolve. 45 00:02:30,480 --> 00:02:32,600 Speaker 1: I see what you mean, because every single issue or 46 00:02:32,840 --> 00:02:36,320 Speaker 1: it takes up time, right, it cuts into your day. Okay, 47 00:02:36,040 --> 00:02:39,120 Speaker 1: So this has been reasonably misleadingly in the way that 48 00:02:39,120 --> 00:02:42,000 Speaker 1: this has been reported because it's been reported as pharmacist EIAs. 49 00:02:42,000 --> 00:02:45,320 Speaker 2: It's not pharmacistias. So do we have a handle? 50 00:02:45,440 --> 00:02:45,640 Speaker 3: I mean? 51 00:02:45,680 --> 00:02:48,080 Speaker 1: Okay, but that makes the whole situation works because now 52 00:02:48,080 --> 00:02:51,160 Speaker 1: we're dealing with doctors making errors. Do we actually have 53 00:02:51,200 --> 00:02:54,200 Speaker 1: a handle though? On the erars that pharmacists make? 54 00:02:55,760 --> 00:02:59,120 Speaker 3: So I'll just correct again, We're not necessarily talking about 55 00:02:59,160 --> 00:03:02,440 Speaker 3: doctor's errors. What we're talking about here is system issues, 56 00:03:03,560 --> 00:03:06,000 Speaker 3: and a lot of those relate, as I've said, to 57 00:03:06,040 --> 00:03:11,560 Speaker 3: how the it works. This is the first insight into 58 00:03:11,600 --> 00:03:15,560 Speaker 3: issues with electronic prescriptions that's ever been done in New Zealand, 59 00:03:15,880 --> 00:03:19,680 Speaker 3: and there's very few around the world. And there's plenty 60 00:03:19,760 --> 00:03:24,400 Speaker 3: of historic reviews of paper scripts in the past which 61 00:03:24,440 --> 00:03:29,440 Speaker 3: showed issues with doctors handwriting and other problems. What we've 62 00:03:29,480 --> 00:03:32,960 Speaker 3: got here in the new world of electronic scripts is 63 00:03:33,000 --> 00:03:35,840 Speaker 3: a new view that we've never had before of a 64 00:03:35,920 --> 00:03:39,880 Speaker 3: completely new and different set of problems. 65 00:03:39,840 --> 00:03:42,600 Speaker 2: And what are the problems that the computers are creating. 66 00:03:43,320 --> 00:03:46,760 Speaker 3: Well, it's a combination of the IT systems, how users 67 00:03:46,840 --> 00:03:51,360 Speaker 3: use them. But what we've found that's very different from 68 00:03:52,000 --> 00:03:56,040 Speaker 3: former audits into paper scripts is firstly, the type of 69 00:03:56,080 --> 00:03:59,760 Speaker 3: issues that we're seeing is very different. We know in 70 00:03:59,800 --> 00:04:05,600 Speaker 3: the past that doctor's handwriting was the perennial problem. Obviously 71 00:04:05,640 --> 00:04:08,960 Speaker 3: we don't have that with electronic scripts, but we have 72 00:04:09,040 --> 00:04:16,880 Speaker 3: a large number of issues with dosing, units of issue 73 00:04:17,120 --> 00:04:21,760 Speaker 3: for pharmacister dispense and other issues, many of which are 74 00:04:21,839 --> 00:04:26,840 Speaker 3: typos in an electronic system model that's got no filtering 75 00:04:27,279 --> 00:04:32,000 Speaker 3: checks and usually no preview before the doctor finally sends 76 00:04:32,040 --> 00:04:36,440 Speaker 3: off the script. Okay, so the type of issues is 77 00:04:36,480 --> 00:04:39,080 Speaker 3: really quite different to what we've seen in the past. 78 00:04:39,200 --> 00:04:41,200 Speaker 1: Yeah, listen, thank you for talking us through a PET. 79 00:04:41,240 --> 00:04:44,240 Speaker 1: I appreciate a Peachandler Midland Community Pharmacy Group. 80 00:04:44,279 --> 00:04:47,360 Speaker 3: See you for more from Hither Dupless Alan Drive. 81 00:04:47,480 --> 00:04:50,919 Speaker 2: Listen live to news talks it'd be from four pm weekdays, 82 00:04:51,040 --> 00:04:53,240 Speaker 2: or follow the podcast on iHeartRadio.