DAA error rates the ‘elephant in the room,’ says MPS


Dose Administration Aids

Error rates are the ‘elephant in the room’ nobody wants to discuss when it comes to DAAs, says Luke Fitzgerald, CEO of MPS.

In September the Pharmacy Board of Australia published revised guidelines that provide guidance to the profession on a range of issues. One of the key issues reviewed was Dose Administration Aids, with new guidelines released.

These guidelines provide additional guidance, some of which includes labelling of dose administration aids and packing of DAAs by a third party. MPS has welcomed these guidelines which take effect today, 7 December 2015.

However MPS says the primary aim of the Pharmacy Board is a focus on patient safety, and that in the past the Board has issued warnings about DAAs where safety has been compromised.

At the same time with an ageing population, who consume many chronic therapy medicines, coupled with significant government funding for DAAs, third party facilitated DAAs are here to stay, it says – saying this is the only way pharmacy can deal with the tsunami of patients that will require a DAA moving into the future.

“Safety is our priority. The ‘elephant in the room’ that no one wants to talk about is error rates,” says Fitzgerald.

“We are all human and errors will occur. It is critical to have systems and procedures in place that minimise any risk of errors.

“What our data shows is that with our MPS packettes our documented error rate is 1 in 80,000 packettes.

“While I would be delighted if that error rate was zero, we also have to be realistic. What I can categorically state is that our specific error rate is significantly lower than any human packing process.

“We are aiming for an error rate of four in every 1 million pouches, to achieve this MPS has embarked on a program of creating a culture of continuous improvement in everything we do.

“The methodology that we will be using is Lean Six Sigma which specializes in facilitating the establishment of sustainable continuous improvement in organisations. Six Sigma quality means that 99.99967% of what we produce and provide will be accurate and delivered correctly and on time to the pharmacies and Aged Care Facilities.

“Furthermore at MPS we have our industry leading stringent checking processes using the MDM – Medication Detection Machine, this process is designed to ensure the contents of the MPS Packette exactly match the medication order supplied.

“If the MDM is unable to get a clear view of any medication, it highlights the roll and further checks are made by our Quality Control Officers.”

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