Near Misses

By Dispex

In the hectic atmosphere of a busy dispensary under tremendous pressure, the most diligent dispenser can
experience a “near miss” or occasionally make a mistake – and that’s normal. After all, we’re all human. What
truly matters is how we address and rectify these dispensing errors!

Errors in dispensing may have wider implications on the patient’s overall treatment and therefore should
be reported and rectified. A process for reporting is needed not with a view to appointing blame, but for
improving patient care, having medico-legal evidence and being able to analyse causes of mistakes to help
prevent future problems. Once the cause has been identified further training could be implemented for the
entire team- this approach fosters an ethos of learning from each other’s mistakes rather than placing blame.

If a major critical error or incident has occurred then the surgery must complete the appropriate ICO or CCG
form, and inform the ICB, Lead GP, Practice Manager, Dispensary Manager and other associated bodies. The
document is then sent to the Risk Management Lead of the ICO or ICB, as per the DSQS guidelines.

Please ensure that your near miss and significant event reporting SOP is current, and that all members of the
dispensing team have read and understood its implications. Members can
login to the Dispex website to
access our comprehensive template. Furthermore, ensure that your team’s competencies and CPD are up-
to-date. For our training options, and a competency check-sheet, please click