Basic Error Prevention Techniques is a 12-Hour home study course covering pharmacist malpractice liability and administration liability for error, pharmacist liability exposure for undesired therapeutic outcomes, risk management strategies for pharmacy practice, special legal requirements for expanded pharmacy practice, systems improvements to decrease errors and improve patient outcomes, and the various types of errors that can occur in a pharmacy practice setting. In addition to 12 hours of general continuing education credits (012-000-04-260-H03), the course has been approved for Consultant Pharmacist Recertification (10-38696).

Pharmacists are held to a standard of care that requires absolute accuracy in order processing. The fact of error speaks so loudly that, when a patient has received a wrong drug, or the right drug in the wrong strength, or the right drug with the wrong directions, a presumption of negligence arises, and the pharmacist is virtually powerless to rebut the presumption. The pharmacist may have been careful and attentive when the prescription was being filled, but what matters is that an error occurred, not how careful the pharmacist was in filling the prescription.

This reality of pharmacist malpractice law places pharmacists in a dilemma. Since: (1) all humans make errors, (2) all pharmacists are humans and (3) error in pharmacy defines negligence; all pharmacists are negligent. In other professions, an "honest error in judgment" rule protects from liability those who have tried their hardest, but inevitably have erred due to the frailty of the human condition. The rule recognizes that human judgment cannot be guaranteed, and that it is unfair to penalize humans for their imperfections when they are doing the best that they can. Yet, in the prescription order processing function, little judgment is used, thus an honest error in judgment rule is inapplicable. In traditional dispensing pharmacy practice, mistakes are not forgiven as the inevitable result of human frailty.

The purpose of this unit is to suggest that the incident report created after a failure of quality has occurred in a pharmacy is the most important first step in a process of critical analysis that can improve outcomes for patients and dramatically reduce exposure to liability for professional malpractice. Part I of this unit reviews the sorts of problems that have led to pharmacist malpractice liability in the past. Part II describes how continuous quality improvement can serve as the basis of prospective risk management activities. Part III summarizes the results of an analysis of 1,238 incident reports from a major pharmacy chain, and concludes that the traditional incident report provides necessary but insufficient information for meaningful quality improvement activities. Part IV discusses corporate responsibility for the quality of pharmacy practice, and the steps that can be taken to use reported failures of quality as the basis for a comprehensive plan of improvement in the future.

Learning Objectives

1. Discuss pharmacist malpractice liability and administrative liability for error
2. Explain pharmacist liability exposure for undesired therapeutic outcomes
3. Discuss appropriate risk management strategies for pharmacy practice
4. Discuss special legal requirements for expanded pharmacy practice
5. Describe how systems improvements can decrease errors and improve patient outcomes
6. Explain and distinguish the following four types of error:
   1. Technical
   2. Judgmental
   3. Normative
   4. Quasi-normative
7. Describe an effective risk management strategy for community and institutional pharmacy practice.

Course Description

Part I Introduction to Pharmacy Errors and Liability Issues

1. Liability for Failures of Quality in Pharmacy Practice
2. Continuous Quality Improvement to Reduce Liability
3. Analysis of Incidents in a Major Chain Pharmacy
4. Shared Responsibility in Error Prevention

Part II Understanding Pharmacy Errors

1. Psychological Correlates of Human Error
2. System Factors in Error
3. Research in Pharmacy Error
4. Analysis of Anecdotal Reports of Pharmacy Error

Part III Error Reduction in Pharmacy

1. Effective System Design and Implementation
2. Individual Competence and Caring
3. Monitoring and Improving

Part IV Appropriate Handling of the Complaint of Error

1. Process of Error Management
2. Content of Error Management
3. Follow-up and Assurance

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The University of Florida College of Pharmacy is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.

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