Amit Kumar (centre), pictured with staffers Neil Patel and Ibrahim Shaik at Unichem Pharmacy in Kopeopeo, Whakatāne, says pharmacists are spending considerable time fixing errors in scripts. Photo / Kathy Forsyth
Amit Kumar (centre), pictured with staffers Neil Patel and Ibrahim Shaik at Unichem Pharmacy in Kopeopeo, Whakatāne, says pharmacists are spending considerable time fixing errors in scripts. Photo / Kathy Forsyth
Pharmacists across Bay of Plenty and Manawatū are spending large amounts of time correcting prescription errors, according to the region’s first comprehensive script audit.
Whakatāne pharmacist Amit Kumar was among staff at 68 community pharmacies – including those in Kawerau and Ōpōtiki – who took part in the week-long auditin September, led by the Midland Community Pharmacy Group and the Bay of Plenty Community Pharmacy Group.
Across the snapshot audit, pharmacists logged 1257 issues in prescriptions from GPs, specialists, midwives, dentists and other prescribers.
Incorrect doses were the most common problem, followed by wrong quantities, missing details or medicines judged “inappropriate” for a patient.
Alarmingly, 26% of all errors had the potential to cause significant harm if pharmacists had not intervened, the Te Manawa Taki Regional Script Audit report found.
It said the pattern of issues “points strongly to IT [information technology] functionality problems rather than clinical errors”.
“The audit makes prescribers look bad, but it’s not entirely their fault. They’re as understaffed as we are. The system is at fault, though prescribers should take some responsibility in safe and correct prescribing.”
An audit found errors in prescriptions issued in Bay of Plenty and Manawatū. Photo / 123rf
Kumar said New Zealand’s prescribing software was seriously outdated.
“The IT we use is 20 to 25 years behind the UK or Australia,” he said.
Electronic scripts became widespread during Covid, bringing a new wave of errors.
“Mistakes do happen and we try our best, but the margin of error is significantly increased when the script is not correct to start with,” Kumar said.
“It is the system to blame,” he said.
The audit report also said e-prescribing had introduced “new risks and inefficiencies” for patients, prescribers, pharmacists and the wider health system.
Health New Zealand Te Whatu Ora acknowledged the software problems highlighted in the audit and supported several recommendations, including wider sharing of the findings, sector workshops, refining audit tools, expanding the audit nationally and investigating how IT system differences affect safety.
“We recognise the critical role of pharmacists and the importance of collaborative efforts to improve prescribing safety and efficiency,” Ed Falloon, Health NZ’s director of digital applications and products, said.
Kumar said IT gaps also contributed to risky communication failures, especially when patients moved between hospital and primary care.
“A patient might leave hospital with three medications stopped. We update their medicines based on the discharge script.
“But the GP may not get that update for six weeks. The patient runs out, goes back to the GP, and gets put back on the old script. If they go to a different pharmacy, the error isn’t caught, and they can end up back in hospital.”
For short-staffed pharmacies, resolving errors added significant pressure.
“We’re a time-poor industry,” Kumar said.
“We’re not paid for the extra time fixing script errors. That time could be spent on actual clinical care.”
The audit found each error took nearly 20 minutes on average to resolve, with complex issues taking up to 40 minutes and some dragging on for days. Meanwhile, pharmacists were typically paid $6.50 per script, according to Health NZ, although Kumar said it was generally $4.35 plus GST.
The report concluded that although training, staffing and clinical complexity contributed to errors, outdated IT systems appeared responsible for “a substantial proportion” of the problems – a trend mirrored in international research.
Falloon said Health NZ was committed to working with pharmacists, software vendors and other stakeholders to improve prescribing and dispensing workflows.
“Addressing legacy IT challenges remains a priority as we work towards a safer, more integrated system. The digital technologies used by community pharmacies are purchased and maintained by the pharmacies themselves.
“Health NZ is not part of any selection process related to these procurements.
“We strongly support pharmacies and general practices to keep their digital assets current and regularly review the value they are receiving from those tools.”
Falloon said the Minister of Health’s new Health Digital Investment Plan would help guide improvements to the safety, quality and usability of digital tools across the sector.
Eastern Bay GP Cecile de Groot said the problems were complex and the report did not capture all the underlying challenges affecting prescribing.
“The issues are going to be compounded by more and more external prescribers coming on board, the availability of up to 12-month prescriptions next year, and the increasing complexity and number of medications that people are taking, prescribed by multiple health services,” she said.
