The store team conduct regular patient safety reviews. This involves collating all the near misses and the dispensing errors to try to spot trends or patterns. Once Identified a root cause analysis is conducted and appropriate actions are taken to avoid a repeat of the near miss or dispensing incident.
On conducting the patient safety review this month the pharmacy technician who leads this process notices that the near misses in the store have jumped by almost 50%. This is a significant difference to previous months. There have been no significant changes in-store so the team are baffled.
Then one of the dispensers points out that our pharmacist has been very distracted with his phone this month, which he used to leave in his locker.