Best of practice for DAA
June 20, 2014
THE Pharmacy Board of Australia
has said it will raise the issue of
serious adverse events related to
errors in prescribing and dispensing
methotrexate with the Medical
Board of Australia and with safety
and quality authorities.
The Board updated its figure for
events, saying it was aware of five
since 2011 (PD 19 Jun), three of
which were under investigation and
two referred to a panel hearing.
Pharmaceutical Society of
Australia (PSA) national president
Grant Kardachi said packing dose
administration aids (DAA) was
valuable to the community as
compliance was one of the biggest
issues for pharmacy.
However, pharmacists needed
to make sure appropriate systems
were in place for this, to minimise
the risk of errors and make sure any
made were picked up ASAP.
Best practice for DAAs was to
review how they were packed, to
make sure there was a dedicated
space to do so in the pharmacy and
to ensure there were dedicated
people who had time set aside to
focus on packing DAAs, he said.
Errors were not common
but needed to be taken
seriously as they could be
minor or catastrophic, as in the
methotrexate incidents, he said.
These highlighted to pharmacists
the need to look at whether they
were doing everything possible to
minimise risk, he said.
Australian Commission on
Safety and Quality in Health Care
pharmaceutical advisor Margaret
Duguid said this was the first time
she had heard reports of errors
made in dispensing methotrexate
into DAAs and that it was a high risk
drug with work being done globally
to reduce associated errors.
Pharmacists needed to be vigilant
about such drugs when packing
into DAAs and ensure they had
systems in place to check errors did
not occur, she said.
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