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Why A UC Researcher Wants Ohio To Monitor Its Pharmacies

U.S. Military
A UC researcher would like to see all community pharmacies self-report mistakes.

The University of Cincinnati researcher who co-authored the first North American study of medication errors is calling on Ohio and other states to require the reporting of mistakes in community pharmacies. Hospitals already have to document such errors.

Neil MacKinnon, Ph.D, dean of the University of Cincinnati's James L. Winkle College of Pharmacy, studied seven years of community pharmacy data in Nova Scotia, the only place in North America where mandatory, anonymous reporting is required. His results have been published in the Canadian Medical Journal.

The findings out of 98,097 quality-related events:

  • The most common mistakes were incorrect dose; frequency; incorrect quantity; and incorrect drug
  • 82 percent of the mistakes did not reach the patient
  • Less than 1 percent were associated with patient harm, including allergic reactions. Two people died

But MacKinnon is concerned those results would be magnified in the U.S. with 67,000 community pharmacies located throughout the nation. He says that would translate into 3.1 million medication errors each year and 29,000 patients who would be harmed.

Credit Courtesy of UC
UC Pharmacy School Dean Neil MacKinnon (center) double-checks students so they don't make mistakes.

"Just like a hockey goalie can't stop all shots, there are some issues that regrettably reach the patient, but the Nova Scotia pharmacists are reporting and learning from these events," he says. MacKinnon is calling on the Ohio Board of Pharmacy to require reporting in community pharmacies.

The Board says it's in the process of adopting mandatory reporting for violations of law. Public and Policy Affairs Liaison Ali Simon says:

In developing this crucial rule, the Board convened a stakeholder group of pharmacists representing several pharmacy practice settings (retail, institutional, etc.). Through the stakeholder group, the proposed rules will require mandatory reporting of a dispensing error that is the result of reckless behavior or unprofessional conduct. This rule has been posted for public comment:
The Board is also in the process of developing a rule requiring the mandatory reporting by pharmacies of an individual who is terminated from employment related to medication errors. This is to identify individuals who may represent a danger to the health and safety of Ohioans.

Commenting on Ohio's actions, MacKinnon says, "While welcomed and helpful, this new requirement, when implemented, would only capture a small fraction of the types of events that are reported by pharmacists and pharmacy technicians in Nova Scotia, Canada, as this only includes those that are the result of reckless or unprofessional behavior."

MacKinnon says patients need to be their own advocate to make sure their prescriptions are error-free.