Pete Chandler: Midland Community Pharmacy CEO addresses the audit revealing thousands of prescription mistakes

Following the death of a two-year old baby in Manawatū earlier this year Midland Community Pharmacy Group chief executive Pete Chandler co-ordinated an audit.

The audit found 1,200 prescription mistakes in one week- 26% of the mistakes posing 'high risk of harm' to patients. 

Chandler told Heather du Plessis-Allan that the days of doctors' handwriting causing issues are over, but electronic systems have introduced a whole new range of problems. 

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Episode Transcript

Speaker 1 (00:00):
Now, you might recall the heartbreaking case of the baby
who died from a medication overdose earlier this year. We
talked about it on the show. After that tragedy, the
Midland Community Pharmacy Group decided to review just how often
prescription eras happen. The findings are staggering, more than one thousand,
two hundred mistakes in a single week, and a quarter
of them carried a high risk of harm. Pete Chandler

(00:21):
is the CEO of the Midland Community Pharmacy Group.

Speaker 2 (00:23):
And with us high Pete, Hi, Heather, did this surprise you?

Speaker 3 (00:29):
It did surprise me very so seeing these reports flag
up on my laptop every few minutes from when we
started the audit.

Speaker 2 (00:37):
Oh wow, were you getting in real time?

Speaker 3 (00:40):
Yeap?

Speaker 2 (00:41):
And so were you sitting there watching it come in?

Speaker 3 (00:43):
I was yeah?

Speaker 1 (00:45):
And what was the feeling was was your heart just sinking?

Speaker 3 (00:50):
I think there are two things that I saw as
one is the frequency of issues being reported, but also
the narrative text that pharmacists wrote a lot side that
explained the nature of repeating issues and so yeah, your
heart does think thinking we really do have a problem.

Speaker 1 (01:07):
Yeah, Okay, Now I feel like in the interest of
being fear it is not just pharmacists who are responsible
for these twelve hundred mistakes, right, it's the doctors as well.

Speaker 3 (01:17):
Correct, But I need to clarify that what we've audited here, Heather,
is a subset of issues that pharmacists have picked up
with prescriptions rather than clinical errors. And there's a really
important difference in that we weren't auditing patient medical records

(01:39):
to find prescriber errors. We were capturing issues that pharmacists
spotted on scripts that needed time to resolve. So that's
a really important distinction.

Speaker 1 (01:49):
Oh, okay, hold on, not on, So we are not
this is not mistakes pharmacists are making. These are mistakes
doctors are making that pharmacists are picking up.

Speaker 3 (02:00):
Five Further, they're not necessarily mistakes, but they are issues.
So the distinction we've made here is that an issue
is not necessarily an error, but it is a problem.
And a lot of these issues do relate to the
functioning of IT systems rather than actual clinical errors. So
it's important to be really clear on that, and that

(02:22):
was the reason why we did this audit to understand
the extent of things that pharmacists were having to work
with GPS to resolve.

Speaker 1 (02:30):
I see what you mean, because every single issue or
it takes up time, right, it cuts into your day. Okay,
So this has been reasonably misleadingly in the way that
this has been reported because it's been reported as pharmacist EIAs.

Speaker 2 (02:42):
It's not pharmacistias. So do we have a handle?

Speaker 3 (02:45):
I mean?

Speaker 1 (02:45):
Okay, but that makes the whole situation works because now
we're dealing with doctors making errors. Do we actually have
a handle though? On the erars that pharmacists make?

Speaker 3 (02:55):
So I'll just correct again, We're not necessarily talking about
doctor's errors. What we're talking about here is system issues,
and a lot of those relate, as I've said, to
how the it works. This is the first insight into
issues with electronic prescriptions that's ever been done in New Zealand,

(03:15):
and there's very few around the world. And there's plenty
of historic reviews of paper scripts in the past which
showed issues with doctors handwriting and other problems. What we've
got here in the new world of electronic scripts is
a new view that we've never had before of a

(03:35):
completely new and different set of problems.

Speaker 2 (03:39):
And what are the problems that the computers are creating.

Speaker 3 (03:43):
Well, it's a combination of the IT systems, how users
use them. But what we've found that's very different from
former audits into paper scripts is firstly, the type of
issues that we're seeing is very different. We know in
the past that doctor's handwriting was the perennial problem. Obviously

(04:05):
we don't have that with electronic scripts, but we have
a large number of issues with dosing, units of issue
for pharmacister dispense and other issues, many of which are
typos in an electronic system model that's got no filtering

(04:27):
checks and usually no preview before the doctor finally sends
off the script. Okay, so the type of issues is
really quite different to what we've seen in the past.

Speaker 1 (04:39):
Yeah, listen, thank you for talking us through a PET.
I appreciate a Peachandler Midland Community Pharmacy Group.

Speaker 3 (04:44):
See you for more from Hither Dupless Alan Drive.

Speaker 2 (04:47):
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