Risk mapping in community pharmacies

Community pharmacists worldwide operate with the continual risk of errors (Quality Related Events-QREs) occurring in their dispensing processes. Contemporary analysis of community pharmacy QREs tends to concentrate on the outcomes of the error, such as the degree of patient harm, rather than on the risks associated with the triggering of a QRE. Drawing on risk identification and mapping techniques from the information security sector, we conducted a risk mapping exercise of QREs occurring in Canadian community pharmacies as identified in publicly available accident investigations. The findings from the present study identified relationships and patterns between various risk factors, types of errors, and patient outcomes. For example, the risk factors most associated with errors that result in patient fatality were the "sound-alike/look-alike" medication labeling and the dispensing checking and verification processes in the pharmacy. Study findings support the application of risk identification and mapping techniques to community pharmacy risk and QRE mitigation practices and regulations.