Pharmacyguildwatch

G U I L D WAT C H
RISK MANAGEMENT
FOR PHARMACY
Guild Risk Services, a Division of Guild Insurance Limited, has produced this GuildWatch Risk Management Guide for Pharmacy. It provides preventative measures from both an insurance and a professional standards perspective to minimise risk. It is a proactive guide to assist you in reducing the likelihood of loss in your pharmacy. The new revised text is divided into sections each with a series of challenges; together with a question-and-answer, risk and quality snapshot to help you assess your pharmacys level of risk. We hope you enjoy the new GuildWatch.
CONTENTS SECTION 1 2
GUIDE TO GOOD DISPENSING

SECTION 2 10
SECURITY & LOSS

SECTION 3 18
PUBLIC LIABILITY
SECTION 4 24
HEALTH & SAFETY

SECTION 5 32
David Roddis Group Risk Manager
PRIVACY CONTROLS
SSECTION 6 34
INCIDENTS & CLAIMS

SECTION 7 36
RISK HORIZONS
INTRODUCTION
GuildWatch, Risk Management for Pharmacy, has been produced in consultation with the Pharmacy Guild of Australia, Pharmaceutical Defence Limited, Pharmacy Board of Victoria and the Pharmaceutical Society of Australia. We thank these bodies for their valuable insights and advice in preparing this document.
Guild Insurance Limited works closely with the profession and its representatives. The Risk Management Committee (which comprises members of Pharmaceutical Defence Limited, the Pharmacy Board, the Pharmaceutical Society of Australia, the Pharmacy Guild of Australia and members of Guild Insurance) meet to review claim trends on a regular basis. This has assisted in producing a Guide that reflects the issues that impact upon your pharmacy. By way of illustration you will find real case studies throughout the document which are indicative of those commonly received and managed by Guild Insurance. Reducing dispensing error, and managing the process if any error occurs, is one of the main themes in this document. However, there are many other incidents that may result in litigation, not the least of which are possible breaches of the Privacy Act and Trade Practices Act. We hope you find the advice timely and practical. The aim is to add value to your business by helping to identify the risks that surround your everyday activities. In addition to this printed document, Guild Risk Services has an on-line self assessment risk management tool, RiskMASTER. RiskMASTER provides an anonymous online survey system which, through a series of questions and answers, assists you to assess your risk profile and your management of risk. Surveys on a range of topics are provided and the resulting report includes advice on steps to take to improve your risk profile or reduce risk. These reports can be used in the professional development for your team. We value your feedback A reader survey form has been included in this publication and we ask that you complete this and return it to Guild Risk Services. We appreciate your feedback.
SECTION 1
GUIDE TO GOOD DISPENSING

Every year millions of prescriptions are filled by Australian pharmacies. As Australia has become more litigious, and as the range and complexity of medications has increased, the need for a highly vigilant approach to controlling risk in dispensing has never been greater.
Challenges Question-and-answer Risk and Quality Snapshot Errors & solutions Common sound-alike and look-alike drugs Risk control steps in dispensing (flow diagram) 3 4 5 7 8
G U I L D WATC H GUIDE TO GOOD DISPENSING
CHALLENGES
Dispensary design and procedural controls are the keys to eliminating or reducing dispensing errors. Here is a list of your main challenges.
Evaluating dispensing processes, equipment and procedures to minimise risk of error. Use of layout and technology to minimise error. Organising storage and product placement so that risk of incorrect drug selection is reduced. Group drugs to avoid similar name and similar strength errors. Use of scanners to enhance the dispensing process. Standardising use of abbreviations and the labelling protocols used by all personnel. Communicate with prescribing doctors where doubt exists in regard to the prescription. Managing workflow and ergonomics for maximum comfort and minimal distraction. Agreeing on communication protocols among all pharmacy personnel in the event of a dispensing error.
Question-and-answer Risk and Quality Snapshot
Work through the following to assess how your pharmacy is placed to mitigate dispensing risks.
DISPENSARY LAYOUT Are phones redirected away from the dispensary? Is the dispensary area removed from distracting sounds? Is lighting high grade and free from glare? Are work stations self contained with their own printer? Are work stations ergonomic in their design? TECHNOLOGY Are database technologies used effectively? Is data entry appropriately quality assured? Are scanners used to provide additional checking support? Is equipment standardised at each work station? STORAGE AND STOCK ROTATION Is grouping by manufacturer not practised? Are strengths of the same drug separated? Are look-alikes and sound-alikes separated? Are unusual or dangerous drugs subject to special protocols? Are drugs restocked so as to rotate stock and avoid expiry? WORKFLOW Is workflow directional to avoid double handling & confusion? Is the pharmacist involved at the beginning and end of the dispensing process? Are dispensary technicians fully utilised to free up the pharmacist? Are interruptions kept to a reasonable minimum? INFORMATION ISSUES Are suspicious scripts checked with the clinician? Are strengths and dosage queried when unclear? Are patient histories used to cross check interactions? Are additional checks in place where multiple clinicians prescribe?
Q
&
Yes
A
Could improve No
Does a protocol exist in the event an error occurs or is suspected? CAUTIONARY AND ADVISORY LABELS Are suitable cautions attached to packaged drugs? Are labels attached so that manufacturer advice is still visible? Are CMIs provided where required?
ERRORS & SOLUTIONS

Because dispensing involves human interaction and judgement (and includes information provided by patients and doctors) errors cannot be totally eliminated. However, they can be minimised both in frequency and severity.
Systems and controls Very few professionals operate in such high-stress settings where distractions are not easy to eliminate and where conflicting demands on the professionals time are made throughout the day. It is therefore very important to review and manage workflow, physical layout and interaction protocols. The volume and variety of drugs handled by a pharmacist requires that care be taken in storing and providing access to them. Here are some of the main ways to reduce error:
USE OF INFORMATION TECHNOLOGY SEPARATION OF STRENGTHS
The variety and volume of drugs on offer makes the use of database-driven dispensing programs essential. But like all such technologies, they are only as good as the way in which they are handled. Basics include: checking of data entered because an error can be multiplied control of access and administrator rights avoidance of double entry of data entry of consistent and decipherable abbreviations and notations update of data on a regular cycle.
USE OF SCANNERS
Dispensing the incorrect strength of a drug (for example Wafarin) can be as dangerous as dispensing the wrong drug! In fact, it is a more likely error; for this reason, strengths should be separated on the shelf, even though the drug is the same and from the same manufacturer.
SEPARATION OF SIMILAR NAMES
Similar names are a fact of life in the industry and an issue further complicated by the emergence of generics. Solutions include: use of scanners absolute separation of similar names and avoidance of a purely alphabetical organisational system prominent display of an up-to-date list of similar names to encourage recognition among the pharmacy team (see table p.7) reorganisation of stock when a new similar name appears.
ROTATION OF STOCK
CLAIM SNAPSHOT A locum pharmacist made a selection error leading to a customer being dispensed anti depressant medication on a prescription for gout medication. The names and the packaging of the two (generic) medications involved were very similar. The customer has alleged that he has sustained significant medical and hospital expenses as a result of the error and made a substantial claim.
Scanners are strongly recommended by Pharmaceutical Defence Limited and Guild Insurance. Where they are used properly, they have been shown to reduce error by providing an additional layer of checking. To review their use in the dispensing process, please refer to the chart on pages 8 and 9.
MANUFACTURER GROUPING
Systems for restocking must be designed so that stock rotation is achieved. This will reduce the risk of dispensing expired goods.
SPECIALIST DRUGS AND HIGH VOLUMES
It may be quicker and easier to replenish stocks if they are kept according to manufacturer. However, the similarity in packaging style between different drugs from the same manufacturer immediately increases the risk of an incorrect selection. If this practice is followed in your pharmacy, consider implementing a new system.
It is recommended that drugs with a greater risk profile (eg, special usage requirements and/or high risk of interaction) are stored separately to the more commonly prescribed drugs.
DIRECTIONAL WORKFLOW
Directional workflow is recommended to help reduce double handling or possible confusion. Each dispensing station should be self contained to avoid risks that may arise from sharing of resources such as label and repeat printers.
ERRORS & SOLUTIONS (continued)

Managing strengths, soundalikes and look-alikes must be the rationale for any organisational system. A purely alphabetical system will not provide sufficient protection from error. Physical separation and clear labelling are both essential.
FORWARD PHARMACY
Irrespective of the pharmacys specific operating arrangements, the pharmacist must be involved at the beginning of the process and at its conclusion. Reducing distractions Perhaps the greatest distraction for the professional pharmacist is that generated by the commercial activities of the pharmacy. Very few professionals are required to provide their skills and knowledge in such an open, potentially noisy, and high traffic environment. This may lead to stress and reduces the ability to concentrate for long periods. Therefore, physically engineering your work place so that you can work with minimal interference is essential for your well-beingand it is also essential for error control. Good design of the dispensary will allow the pharmacist to interact with patients for counselling but will also provide privacy and quiet to improve concentration. Basics include: redirection of all incoming phone calls to the service counter and space separation between dispensing and commercial functions in the pharmacy use of sloping drawers, caroussels and other devices to systematise, and reduce inconvenience properly designed work stations including sufficient room, dedicated label and repeat printers, adjustable heights for benches and fittings excellent ergonomics including noise control and ergonomic workflow management (eg, avoiding double handling, stretching and bending) high levels of illumination appropriate to the environment staff training as to when and how to interact with the pharmacist. At all times it must be remembered that patient counselling and consultation are the primary roles of the pharmacist. Dont let other distractions get in your way.
Information-related problems The practice of pharmacy requires excellent management of information from distinct sources: pharmaceutical knowledge, prescriptions from clinicians, and information provided by the patient or their care giver. The variety and multitude of sources of information can cause problems. Here is a list of the common causes of error:
RIGHT DRUG WRONG STRENGTH
Similarities between packages can cause a dispensing error (again, scanning technologies will assist with capturing such errors). Other causes include: doctor error in dosage prescription inconsistent use of abbreviations transposition of quantity, strength and /or frequency Well set up patient histories can assist in quality assuring dosage and strength.
PRESCRIPTION QUALITY
CLAIM SNAPSHOT A pharmacist dispensed Wart-Off to a customer as he did not stock Wartec. Wartec is designed for use in the treatment of warts around the genital region whereas Wart-Off is contra indicated. The client sustained chemical burns, leading to a claim being made. CLAIM SNAPSHOT As a result of difficulty reading a prescription sent by facsimile, the pharmacist dispensed an excessive dose of opioid analgesic. This led to the elderly patient becoming drowsy causing her to fall and sustain significant injuries. Her family claimed substantial compensation.
Pharmacists must rely upon the information supplied to them. However, a critical approach is required to deal with the following key issues: unclear handwriting or instructions obviously incorrect scripts. Where information is doubtful, the pharmacist should always check with the prescriber.
INTERACTIONS
Because the pharmacist is a central point of contact in a patients care, the pharmacist should routinely check the patients history for interactions or other warning signs. Pharmacists should be alert to interactions when processing scripts provided to one patient by a variety of clinicians. Obviously, the doctors should likewise be checking; however, where your records show a likelihood of adverse interactions your dispensing practices may be called into question in an adverse event.
HUMAN ERROR AND FATIGUE
There are obvious limits on the capacity of any individual to work in an error-free manner over long stretches of time. A planned work day with some element of job rotation and breaks is therefore prudent.
ERRORS & SOLUTIONS (continued)

It is acknowledged that as the number of scripts increases the likelihood of an incident arising from a dispensing error also increases. Obviously, the nature of the script dispensed has an influence on the time taken. As an example, for a person to dispense 160 scripts per day at an average of three minutes per script equates to 480 minutes or eight hours. This does not include any time for breaks or other issues. On an ongoing basis this is a cause for concern, as the potential for a claim may increase depending on the script dispensed.
EXTEMPORANEOUS DISPENSING/COMPOUNDING
CLAIM SNAPSHOT A pharmacist dispensed generic long acting insulin rather than short acting. The patient did not realise until away on holiday in a remote place where he used it and significantly compromised his health. The customer claimed the cost of the ruined holiday.
State and Territory Pharmacy Board Guidelines and PSAs Professional Practice Standards.
CORRECT USE OF CMIS
CMIs are not a substitute for patient counselling as patients often require and expect some explanation and reassurance. Refer to the PSAs guidelines on Consumer Medicine Information and the Pharmacist.
PRESCRIPTION REPEATS
Where repeats are provided by the clinician, it is inadvisable to dispense them all at once. This type of practice is discouraged as it puts people at risk. These risks include: large quantities of a drug in a persons household prescribed medication may change but patients may continue taking old medication.
Particular care should be exercised by pharmacists who are requested to dispense medicines extemporaneously for which there are no precedents in the standard references or who are requested to, or choose to make alterations to proprietary medicines. Refer to
COMMON SOUND-ALIKE/LOOK-ALIKE DRUGS

Adalat Akamin Aldactone Aldactone Aldomet Alphapress Alprim Amantadine Amaryl Amaryl Amfamox Amitriptyline Amoldipine Amohexal Amorolfine Amoxycillin Anaprox Apomine Aratac Arima Aropax Arthrex Atacand Atrop Augmentin Aurorix Auspril Avandia Avanza Avapro Aldomet Aclin Aldazine Aldomet Alodorm Alphapril Solprin Cimetidine Amoxil Reminyl Alphamox Aminophylline Amiloride Atohexal Aminophylline Ampicillan Aprinox Avomine Aropax Arimidex Aratac Aururix Atacand Plus Azopt Augmentin Forte Aropax Auscap Avanza Avandia Avapro-HCT Beclomethasome Beconase Betaloc Burnetanide Capoten Carafate Carbimazole Cardizem Cipromil Cisplatin Clomid Clomipramine Clomipramine Cortisone Daonil Deptran Deptran Deptran Desferal Diaformin Diamicron Dicloxacillin Didronel Difflam Dimeryl Dithiazide Dothiepin Doxepin Efexor Endep Betamethasone Becotide Becotide Budesonide Gopten Caltrate Carbamazepine Cardiprin Ciproxin Carboplatin Atromid Clomiphene Chlorpramazine Cordarone Deseril Ditropan Endep Ditropan Deseril Diamicron Diamicron-MR Flucloxacillin Didrocal Differin Reminyl Ditropan Doxepin Dothiepin Efexor-SR Deptran Ergotamine Fluoxetine Gemfibrozil Glipizide Hydroxyzine Imdur Imdur Imipramine Imipramine Ketotifen Kalma Lamictal Lamictal Lamisil Lanivudine Lasix Lasix Lasix Levlen Lipex Lipidil Losec Lovan Maxolon Micardis Miloride Mobilis Mogadon Monoplus Monopril Ergometrine Paroxetine Gabapentin Glicazide Hydralazine Imuran Ibilex Clomipramine Trimipramine Ketoprofen Kaluril Largactil Lamisil Lamictal Lamotrigine Lasix-M Losec Lescol Logynon Lipitor Lipazil Prozac Luvos Moxacin Micardis-Plus Amizide Movalis Maxolon Mobilis Monoplus Norfloxacin Ciprofloxacin Norimin Norinyl Norvasc Normison Panadeine Forte Prednefrin Forte Panafcort Panafcortelone Paroven Proven Paxam Paxtine Pethidine Prothiaden Pramin Pressin Prednisolone Prednisone Prednisolone Risperidone Quinine Quinidine Rocaltrol Roacutane Rosig Zomig Seretide Serevent Serevent Seretide Seroquel Serzone Tenoxicam Tamoxifen Thioridazine Thyroxine Tramal Tramal-SR Trimipramine Trimeprazine Vasocardol Veracaps Xalatan Xalacom Zantac Zyrtec Zestril Zyrtec Zinvit Zinnat Zocor Zestril Zocor Zoton Zoloft Zocor Zyprexa Zyrtec
The chart above is an alphabetical list of common drugs which look-alike or sound-alike. Source: PDL 2006 annual report, with permission.
G U I L D WATC H
RISK CONTROL STEPS IN DISPENSING

STAGE I RECEIVAL
RISK CONTROL The script is received and registered on the system. Its legality is established and contact details and key personal data is confirmed.
ACTIVITY Patient details Name Address Phone number Mobile number Concessional entitlements Medicare Number Allergies Child's age Weight (remote/rural: where will be next stop) Prescription details Date Doctor's signature S4 requirements S8 requirements HIC Authority Approval Labelling Check directions on label against those on the original script Expiry date Drug, strength and quantity Attach label to product leaving bar code exposed Scanning and screen double check Scan barcode and re-check screen for: Patient name and address, and date Drug Strength Selection against script Drug Strength Quantity
STAGE 2 PROCESSING
RISK CONTROL The computer record is checked for abuse, interactions and information needs (CMIs). The label is attached and scanned for a double check. The screen is checked during the scan.
ACTIVITY Checks against patient history Enter script into computer checking for: Change of dosage Interactions Evidence of misuse
G U I L D WATC H
STAGE 4 COMMUNICATION
RISK CONTROL The finished items are presented for collection. Counselling, if necessary, provided.
STAGE 3 ASSEMBLY
RISK CONTROL The near-finished items are collated and additional warnings affixed.
ACTIVITY Packaging and warnings Attach appropriate cautionary and advisory labels Place in container which leaves all items visible, with relevant paperwork
ACTIVITY Communication Determine level of counselling required Provide CMI if required Maintain privacy and confidentiality Consider special needs of patient Double checks Verify drug against script Verify recipient
The steps advised above are based on the Quality Care Pharmacy Program. They are aimed at reducing or eliminating dispensing error including: wrong drug, wrong strength, interactions, misinformation and patient medication abuse.
SECTION 2
SECURITY & LOSS

Dispensing best practice must be matched by management of security, premises and goods as pharmacies operate for long hours and therefore have specific risks to control in these areas.
Challenges Question-and-answer Risk and Quality Snapshot Cash & negotiables Security systems Theft; fraud Stock; agencies 11 12 13 14 15 16
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G U I L D WATC H SECURITY & LOSS
CHALLENGES
Security systems reduce loss and protect your valuable business assets. How do you currently measure up against these key challenges?
Handling cash securely by using both a time delay safe and clearing registers during the trading day. Daily banking. Cash held overnight should be moved to a cash-rated safe.
NOTE: A store refit or extension can create security blind spots. At the time of any such renovations, ensure that security systems are not compromised. It is often wise to have a security audit carried out to check that security remains adequate.
Displaying prominent signage that communicates the use of security and surveillance systems. Training all staff on how to respond safely in the event of an armed robbery. Ensuring physical barriers to all forms of unauthorised entry are in place and adequate. Securing all access points (eg, skylights), not only windows and doors. Installing closed circuit television (CCTV) to deter shop-lifting and malicious damage and create a record for investigation. Installing good quality burglary and smoke alarms that are monitored to Grade 1 standard. Managing stock losses including theft, and spoilage; securing high-value stock. Training on fraud, and the use and abuse of credit cards, cheques and concessions.
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Work through the following checklist to assess how your pharmacy rates.
Q
&
Yes
CASH AND NEGOTIABLE INSTRUMENTS Are registers anchored and cash drawers locked? Are registers left empty and open after closing? Is minimal cash held in registers in accordance with QCPP? Is cash cleared directly to a time delay safe? Is banking completed daily so overnight cash is minimal? Is the cash drop safe on a time delay and anchored to the wall/floor? If on a keypad system, is the code regularly changed? Do you display signs stating that time delay safes are used? Do you train new staff on safe response to robbery? SECURITY SYSTEMS Are all windows and doors reinforced and secure? Are all access points (such as skylights) secured? Is illumination at night sufficient to discourage thieves? Is the rear entry well lit and secured? Are glass break sensors and reed switches installed? Are deadlocks used on all windows and doors? Is CCTV installed, especially in high risk areas? Is your alarm monitored by a Grade 1 monitoring company? Does the alarm have a back up system in place? Are smoke detectors linked to the monitored alarm? THEFT; FRAUD Are blind spots avoided with mirrors and CCTV? Are cash registers and other high value areas covered by CCTV? Is a master keying or pin code system used? Is the use of CCTV prominently advertised? Are staff trained in how to respond to shoplifters? Is an employee anti theft policy in place? Are controls such as audits used to control supplier theft? Is fraud training carried out and are internal controls used? STOCK; AGENCIES Is responsibility for cash collection clearly understood/contracted? Is the ATM the total responsibility of the supplier?
Could improve
A
No
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CASH & NEGOTIABLES

Theft is a crime of opportunity; reducing the opportunities to gain access to cash is therefore the driver of managing cash and other negotiable instruments in a way that will lessen the likelihood of robbery.
CLAIM SNAPSHOT A Victorian pharmacist took a call from the alarm monitoring company at 3.00am. A number of the alarm sensors had been triggered. The alarm company contacted police; however the pharmacist himself attended at the pharmacy. As he shone his headlights through the shop window, two heads bobbed down behind the dispensary. The pharmacist blocked the front entrance to the pharmacy with his four wheel drive and had an anxious wait until police arrived. Unbeknown to the pharmacist the offender/s had chiselled out the concrete around the bricks of the neighbouring premises and gained entry at that point. More than $10,000 worth of perfume was stolen. NOTE: Please remember at all times the monitoring company or police should attend the pharmacy on suspicion of a break-in. A Pharmacist should never attend a break-in by themselves. Managing cash securely Large amounts of cash held in the cash register will increase the risk of robbery and of employee fraud.
THE CASH REGISTER Responding to a robbery in progress
Your cash register should be anchored and hold minimal cash. More importantly, minimal cash holding should be communicated with signage so that the incentive to conduct an armed hold-up (or break & enter) is reduced.
TIME DELAY SAFES: A DETERRENT
New staff should be given training on the appropriate way to respond in the event of an armed hold-up. These events are stressful and the aim is always to protect life first and foremost. In the event of an armed hold-up: keep calm and never argue never try to talk a robber out of it never argue, criticise or stare inform of possible surprises such as a staff member in a back room make no quick movements be honest about all available money never chase a robber.
Responding after the event
A time delay safe should be used to store cash taken from the register throughout the day. Note that such a safe will still allow later access, but on a time delay. A standard, quickto-access safe may place staff under extra risk during a hold-up if they are asked to open it. The majority of thefts are conducted in just a few minutes. Time delay safes cannot be opened on request. They can also be linked to remote monitoring which will activate an alarm and notify of a crime in progress when access is attempted in a certain way. Such safes are therefore a deterrent. Prominently displaying that they are used strengthens the deterrent.
DAILY BANKING
It is preferable to bank the days takings daily. Vary your banking routine so that the pattern is not predictable. Owners must consider who is accountable for banking and ensure that the staff member is provided with basic training on their personal safety when carrying out this duty. Professional cash carriers will minimise risk to staff. Reconciliation of cash from the register should be done throughout the day so that no staff member is required to count a large sum of cash at one time. Counting of cash should be done in a secure area out of public view. If cash is held overnight, a time delay and security-rated safe is desirable.
Your actions after a robbery are vital: the pharmacist should take control call 000 and ask for police; tell them We have had a hold-up lock the pharmacy; ask witnesses to stay until police arrive the scene, particularly any surfaces touched by the robbers, should be preserved until police arrive do not discuss the event; rather ask witnesses to jot down independent notes. Comparing stories will weaken evidential value do not discuss the event with the media call Guild Insurance for assistance. Regaining control of the pharmacy is vital. It is recommended that those involved receive trauma counselling because no matter how they feel on the day, an extraordinary and frightening event can produce a delayed reaction. Counselling will assist in managing this potential reaction.
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SECURITY SYSTEMS
The aim is to make it very hard to gain access; and if access is achieved, encourage the offender to leave without further damaging the property.
External security There is a range of measures that can be taken to dramatically lower the risk of a break and entry crime at your pharmacy.
ALL ENTRY POINTS
Internal security Internal security measures reduce risk during open hours, and damage from burglary.
PROCEDURAL
It is important to secure all entry points (not just the main doors and windows). In particular, sky lights, maintenance access, rear entry points and toilet windows should be fully protected.
ILLUMINATION
Opening and closing procedures should be in place and staff trained in them; otherwise, security systems may not be properly used.
KEY SYSTEMS
CCTV and signs advertising your security investment act as deterrents. Glass break/ impact sensors, reed switches and strong locks help discourage an entry prior to it being attempted. Monitored alarms provoke a response. The supplier should provide a Grade 1 standard of monitoring where the owner, security guards and police or emergency services will receive the appropriate alert from the monitoring station.
After hours and late night trading are vulnerable times with darkness providing concealment opportunities. A well lit premises (including rear entrances) will discourage opportunistic crimes and acts of damage. If motion sensors are used they should be of good quality.
SECURITY PATROLS AND ALARMS
The key system for the premises should be a master system or an electronic keypad system. These enable proper control of staff access and accommodate staff turnover.
INTERNAL SECURE AREAS
Areas that store high value items (stock, specialist drugs, records or info-tech) should have additional security measures.
CCTV
Patrols provide a visible presence but must be used with monitored alarms.
PHYSICAL DETERRENTS AND SENSORS
Digital computer-driven video monitoring has become far more affordable. Its use is known to discourage theft from all sources.
MONITORED ALARMS
Well developed solutions include: shutters and grilles are highly effective, but may not be appropriate in some locations reed switches on doors and windows, and vibration/glass break sensors, sound an alarm when a break-in is attempted reinforced glass with break detectors makes entry more difficult bollards where there is a reasonable risk of a car ram-style entry deadlock-style locks on all windows and doors and a security door on rear access.
ADJOINING PREMISES
Sometimes an adjoining premises can pose a risk. This is difficult to control. A neighbourhood watch-style committee can be formed to encourage awareness and consistent practices between traders.
A monitored alarm with a back up system is preferred. The monitoring company should be Grade 1 under the Australian standard. If a dialler system is used, check that a GSM or other back up system is in place. Also, where a dialler system is used, compare the cost-benefit of this including the phone costs as it may not be the most economical system. A good monitored alarm includes: response provided by the supplier, and alert to owner, guards and local police attendance of third party (not staff) at a callout (lower personal safety risk) careful placing of detectors and checking of their effectiveness (especially if store layout changes) awareness that false alarms indicate faulty design of the system linking of smoke detectors to the monitored alarm.
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THEFT; FRAUD
Theft and fraud by shoppers, employees or suppliers must be handled carefully as there are a number of potential legal issues in making such an accusation.
Introduction While it is very upsetting to have your trust abused, to avoid unpleasant legal disputes you must be careful how such thefts are handled. Loss prevention has a clear cost benefit with estimates suggesting possible losses from theft as high as 3% to 5% of turnover.
SHOPLIFTING
Customer fraud Fraud carried out by customers will include the following: illegal scripts for harder drugs returns and refunds passing off identity price switching cheque fraud credit cards
CONTROL CONCEPTS These include:
Internal theft does happen and needs to be managed. A culture of control including written policies will reduce incidence as it will suggest that the behaviour will not be tolerated. Shoplifting can account for inventory loss by between 3% and 5%. For this reason, CCTV, mirrors, entry buzzers and the like are sound investments. Supplier theft must be considered, and the receipt of goods should be a formalised process.
Signs must be displayed indicating that customer bags will be searched when leaving. Signs advising the use of CCTV (video surveillance) in operation are also required under law. Other signs include the use of time delay safes for cash, premises monitored 24 hours, etc. All signage is a good deterrent to theft.
ELIMINATING BLIND SPOTS
carefully checking scripts, especially suspicious notations observing a pattern of repeated script presentation requiring receipts for returns and displaying a returns policy checking prices which seem incorrect seeking ID for all cheques or having regular customers register for use of cheques checking signatures and file records automated card processing so that over limits can be identified. Staff should be trained to spot fraud and should be encouraged to adhere to procedure if a customer is trying to hurry them or confuse them. Employee theft This is an unpleasant occurrence and requires a culture of vigilance. Aspects of effective control include: employment contract clauses stating clear consequences for acts of theft a policy on minimising theft character references (verbal) and detailed reference and job history checking
Store layout should make it difficult to conceal theft. Appropriately placed convex mirrors are a useful measure for revealing blind spots. Video monitoring should also be used to ensure there are no areas obscured from view. Remember if you cant see it then it can be stolen!
ACCESS CONTROLS
Access to high value stock should be controlled. Items of higher value such as perfume should be close to staffed areas, and should also be locked behind glass.
ELECTRONIC STOCK TAGS
When considering the amount of stock to be tagged weekly, also take time to consider the cost-benefit of this control method. A response plan is also necessary as staff should not be encouraged to pursue an offender.
GREETING CUSTOMERS
Just the act of greeting customers reduces risk of loss because visitors become aware of the staff presence and that their presence has been identified/acknowledged by staff.
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THEFT; FRAUD (contd)

use of CCTV where valuables are handled Employee fraud does happen; and it occurs when trust is not supported by adequate checks and balances to control processes and sign offs. Note that good systems also protect staff from that uncomfortable feeling when something goes missing (for example a sum of cash) and there is no audit trail. double checking and counter signatures for purchases and requisitions some form of policy on incidental stock which can be pilfered (eg, consumables) stock reconciliation staff discounts on products. A combination of these practices will limit the temptation to steal and to pilfer. Employee fraud Fraud carried out by staff is often incremental and difficult to detect in the early stages. Skimming of stock or receipts, failure to ring up sales and discounting for known acquaintances are some of the ways in which this can occur.
CONTROL CONCEPTS
rotation of jobs, especially checking and audit roles separation of roles and accountabilities locked access to areas where cheques and other negotiable instruments are held. Supplier theft Pharmacies have a wide range of suppliers, and suppliers come and go. Aspects of effective management controls include: check goods received and match to invoices; demonstrate vigilance by carrying out random in-depth audits; check before signing for deliveries try to avoid suppliers stocking shelves have a staff member involved in receipt of goods and take special care with new suppliers carry out mini stocktakes before and after shelves have been restocked keep accurate sales records so that any discrepancies can be spotted. contractual clauses may be needed to eliminate doubt and suspicion where high value goods might have gone missing.
Losses may be incremental or a large one-off loss. Either way, the impact is unpleasant so it is desirable to put controls in place which discourage fraud related behaviour. two signatures for requisitions and cheques small sums in petty cash
STOCK; AGENCIES
Introduction Stock control is a big part of managing a pharmacy. There is a wide variety and large volume of goods, and often limited space in which to handle and store them. This raises various issues relating to loss control, including those arising from safety considerations and those arising from spoilage and asset protection.
SAFETY ISSUES
Space is often at a premium; however, stock should not be stacked so high that it may cause injury if it fallsor risk of injury when retrieving it.
THE KEY ISSUES OF LOSS ARE AS FOLLOWS:
stock rotation and ordering regimes which avoid stock shortages and lost sales, but also avoid surplus stock damage of goods when unpacking and confusion as to liability spoilage and contamination the treatment of goods requiring temperature control the receipt of high value (as opposed to bulk) goods; especially who takes receipt and where they are stored and under what security conditions.
The safety issues include: manual handling considerations, especially strains and repetitive movements safe access and trip and fall hazards using knives and cutters to open packaging.
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Protocols, including internal sign offs, may be needed to eliminate doubt and suspicion where high value goods might have gone missing. Loss control for stock includes proper rotation and inward goods receipt. High value chilled goods must be carefully protected, and temperature sensitive goods maintained at their recommended temperature. Refrigeration Not all losses are a result of theft. The storage of items requiring refrigeration has increased over recent years. Inappropriately rotated and poorly stored refrigerated stock is increasingly resulting in losses, and increases the potential for customer harm. Refrigerators used traditionally for vaccine storage have become the store space for a number of additional items. Issues include: Capacity of the refrigerator used. Does it provide sufficient physical space to store and keep its entire contents at the ideal temperature? Over loading can impact cooling capacity. A larger unit of greater capacity will operate more efficiently than a small overburdened unit. Is refrigerated stock being rotated to ensure ageing stock is selected first? Are refrigeration temperatures monitored and logged regularly to identify any failures or temperature variations beyond tolerance? Is the temperature displayed? Is the equipment regularly maintained, cleaned and serviced? Is protection in the form of surge arrest provided to these items to protect from damage? The refrigeration unit used should be of high quality, and high reliability and dedicated to the storage of pharmaceutical and medical substances only. Is there a back up in the event of power outage?
Banking agencies If a pharmacy takes on a banking agency or ATM, the following should be in place: excellent external, physical, access control monitored alarms, reed switches and vibration sensors, silent duress alarms (used in the event of a hold-up) CCTV throughout the pharmacy time delay drop safe for cash storage during the day cash rated overnight cash safe use of professional money carriers for banking (note that some will not insure cash and if this is the case you will have an exposure). The best ATM solution is where the bank installs and maintains the device and is completely responsible. When considering an ATM, check the following: who is responsible for the cash who is responsible for maintenance quality and cash rating of the ATMs safe (some are not rated so you may be exposed after a break-in) operation of the ATM (some require new notes) hidden costs in the proposed benefit.
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SECTION 3
PUBLIC LIABILITY
The key to mitigating liability incidents in the pharmacy is to take a common sense look at the environment and procedural controls and identify (and then control) the foreseeable risks.
Challenges Question-and-answer Risk and Quality Snapshot Legal concepts; access Layout and services 19 20 21 22
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G U I L D WATC H PUBLIC LIABILITY
CHALLENGES
The duty of care is a core legal principle. Addressing the following challenges will assist you in complying with this duty.
Understanding core legal principles, and defining the limits of your duty of care. Controlling the immediate environment of the pharmacy and notifying risks to property owners. Providing safe access and egress. Reducing risks of slips, trips and falls. Marking large glass expanses so they are easily identified, reducing the risk of people walking into them. Designing fixtures and fittings so that they are safer and less prone to cause injury. Ensuring that boxes and goods are stored securely so as not to create a hazard to staff or customers. Thinking child safe and user friendly in laying out aisles and displays. Cleaning the premises without creating an additional hazard.
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The following questions will help you to identify some of the basic steps in meeting your duty of care.
UNDERSTANDING, TRAINING, RISK MANAGEMENT Is basic knowledge of legal liability included in staff induction? Is a proactive approach taken to risk control? Are regular reviews of the premises and operations carried out? Are records kept of actions taken and advice given to staff? Is written notice given to landlords about possible risks? Are temporary signs just that temporary? ACCESS, SURFACES, ILLUMINATION, AISLES Is glass marked to avoid mishap? Are paths and steps free of obstructions? Are floor surfaces even and free of trip hazards? Is the car park, if available, properly marked out? Is illumination both at night and in the pharmacy adequate? Are aisles able to accommodate prams, frames, wheelchairs? DISPLAYS Are displays secured so that they cannot fall on people? Are signs hanging from the ceiling well secured? Are the corners of shelves rounded, or covered with rubber? Are sharp spikes and hooks stoppered with rubber? Are goods stored in a safe way (ie, not too high, hard to retrieve)? Are walkways free from electrical leads? Is restocking carried out safely at quiet times or after hours? Is stock presented safely so it cannot fall on people or obstruct? CLEANING Is cleaning carried out after hours? Are spills cordoned off, cleaned and warning signs displayed? ANCILLARY SERVICES Is customer privacy considered and acted upon? Is consent considered where health services are provided? Is health and safety procedure (for services) adequate? Are stringent hygiene practices adopted? Is the safety of equipment regularly checked? Is access to equipment limited?
Q
&
Yes Could improve
A
No
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LEGAL CONCEPTS;ACCESS
Whether you are an owner or occupier of a pharmacy premises, you will be liable for accidents which occur in the space which you manage; sometimes, your liability may extend beyond the borders of the lease or title.
What is liability? The courts tend to interpret duty of care very broadly. You must be able to demonstrate that you acted appropriately and with due regard to safety. Management records will play a significant part when defending any action. It is advisable to keep a simple file on the various steps you have taken to review operations and to advise staff of actions to be taken to mitigate risk. To avoid being negligent, the law requires you to exercise your duty of care to the public at large. You must eliminate or control dangers which may give rise to personal injury or property damage, including properly managing business activities that may give rise to a risk of injury.
PROACTIVE APPROACHES TEMPORARY SIGNS ARE TEMPORARY
Mounting a temporary sign where a problem is identified is a prudent step to lower risk and show care. However, relying indefinitely on such a sign will have the opposite effect, if you could reasonably remove a hazard. Permanent signs should only be used where they encourage cautious behavior in what is an otherwise safe environment. Safe access to your premises Access to and from the pharmacy is one of the major sources of liability risk.
GLASS
To avoid liability for negligence, you must meet your duty of care to others. You must take reasonable care to avoid acts or omissions which you can reasonably foresee would be likely to cause injury or property damage. In the case of your business, this would include those at your business premises, visitors and neighbours. It can be seen that those to whom you owe a duty of care is broad. You must therefore be proactive in your business to reduce risks to the public in pharmacies, due to the long hour/high traffic environment, the risks to the public are real and can be substantial in the event of an accident.
CONTRIBUTORY NEGLIGENCE
Glass is a great design feature, but it must be marked so that those entering the pharmacy do not mistake it for a doorway and injure themselves. Signs and markings should be used to distinguish glass from an open door.
PATHS AND STEPS
CLAIM SNAPSHOT A lady walking through a laneway at the back of a pharmacy put her foot into a deep hole which was not easily visible. She fell, sustaining a number of fractures. The hole was located at the rear of the pharmacys premises and it was alleged that it had been caused by water running from the pharmacy. The injured lady threatened to sue for substantial damages.
Sometimes a customer might do things that are dangerous (especially young children). This can contribute to the cause of an accident, but the law tends to take the view that an occupier should manage for worst cases so these contributions are acknowledged but discounted. In practice, this means that you must look at risks very conservatively.
NOT MY PROBLEM
Paths should be free from obstructions or protrusions such as overhanging branches, or changes in surface (for example pavement which has dropped). Steps are not advisable;. If they are present, they should be sound and, if more than one or two rises, a secure handrail should be considered.
CAR PARKS
Where you offer parking you must manage the space. Basics include: excellent lines of sight for access (eg, trimmed shrubbery and no visual obstructions) marked parking bays and traffic flow (arrows and entry/exit signs) no pot holes or uneven surfaces excellent illumination for low visibility times (dusk, dawn and bad weather). Where you are party to a communal parking lot, provide written notice to those managing the space of any concerns you may have.
Where you lease your business premises, it pays to be vigilant in reporting risks in the vicinity (in writing) to those responsible for the area (whether landlord or council). Because you are operating the business and inviting customers, you must demonstrate that you took your duty of care seriously. Your lease may in fact make you directly accountable for entry areas in a shopping mall, or for parking and other spaces even if they fall outside the boundary of your premises.
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LAYOUT AND SERVICES

How you organise the internal environment of the pharmacy will influence its risk profile. Likewise, the services you offer will carry certain risks.
glassware, pottery, or other sharp or weighty objects ensure that covers pinned to display tables will not catch feet or prams, wheelchairs and the like secure all objects so that they cannot come loose and fall on a customer (examples include signs hanging from the ceiling, video display terminals running in store promotions and shelves and racks).
SHELVING
Floor surfaces Trips, slips and falls are a large source of claims, some legitimate and others not. To protect your customers and your business, the following principles apply: where there is a change in surface or height mount a sign purchase industrial grade coverings and mats with non-slip backing replace frayed or torn mats replace or repair torn, ripped or creased carpets replace cracked, and secure loose tiles warn of potential slips in wet weather (with a sign) or, better still, use non-slip tread. Where a spill occurs, do not leave it unattended, and use a portable sign warning of the danger and cordon off the affected area. Illumination Good quality illumination will reduce risk of accident and prevent concealment of offenders who may enter the premises after hours. Fixtures and fittings Pharmacies offer a wide range of products and have permanent, mobile and temporary displays of various kinds. All have potential risks.
DISPLAYS
Trips, slips and falls are of particular concern to pharmacies because of the high number of elderly, and incapacitated people among the customer base. For this reason pharmacies must pay extra attention to floor surfaces, steps, uneven surfaces and so on.
Shelves, hooks and spikes are a potential danger as they may contain sharp ends which can cause injury if customers fall against them. The corners on low-level shelves are a particular risk to children. Steps to be taken to reduce risk of injury include: rubber stoppers on the ends of hooks and spikes, and the positioning of hooks and spikes so that risk of a mishap is low bevelled edges and rounded corners on all shelves; or rubber stops/plastic caps retrofitted to pre-existing shelves with sharp corners. Aisle width and obstructions While space must be used to maximise commercial results, consideration must be given to access and egress. Aisles should be wide enough to accommodate prams, pushers, wheelchairs and walking frames. This way, stock will not be pushed from shelves with the risk of damage to stock or personal injury.
ELECTRICAL LEADS
CLAIM SNAPSHOT An elderly lady exiting the pharmacy fell heavily sustaining serious injury necessitating hospitalisation. The lady alleged that she had fallen as result of movement of a mat under her and threatened to sue.
Displays pose a special risk as they tend to change regularly and may be supplied by third parties. The basics include: where mobile displays are used at the entrance, ensure that wheels are pointing inwards to avoid a trip where cardboard displays are used and goods mounted on temporary devices, ensure the display cannot collapse and cause harm, especially if it contains
It is inadvisable to run leads in public areas, as they can cause a trip or fall. Note that even taping a lead down still poses a risk. If suppliers wish to provide back-lit displays, they need to be positioned so that that leads do not give rise to mishap.
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LAYOUT AND SERVICES (continued)
Handling stock Pharmacies are high traffic businesses so it is not always easy to restock without causing inconvenience to customers. Staff can often get called away during the process, leaving boxes on the floor which can (and have) cause trips and falls. Liability relating to the provision of health services should be carefully considered. Risks include those relating to handling biohazardous substances, consent and patient confidentiality. It is therefore advisable to train staff on the risks posed to customers by restocking activity, and to try to carry out restocking at quieter times or cordon off the area.
STABILITY OF STOCK
Expertise and qualifications can be an issue if a claim arises, and the pharmacy must comply with all legislative requirements and regulations. Privacy is an important issue and addressed in Section 5 of this Guide. Some services will require a private room for their delivery. When providing ancillary services it will be necessary to obtain written consent from the customer, particularly when carrying out procedures on minors, such as ear piercing.
AGENCY AND NON MEDICAL
Boxes do not provide strong support, so storing stock on boxes can be a risk, especially to young children and particularly if stock is stacked too high. Ensure that stock is well secured. Cleaning Cleaning is a routine pharmacy task but it has inherent risks for both staff and customers. If possible, routine cleaning should be conducted after hours. Claims have arisen where customers have tripped on vacuum cleaner leads and hoses.
SPILLAGE
Risks associated with agency and nonmedical services will include those related to contract and product/service standards. Photofinishing includes possible risk of liability where images do not develop correctly, safety issues with respect to chemicals and staff training. The advent of digital photography is lessening these concerns. A particular issue is what to do if illicit images or films such as child pornography are asked to be processed. In general, agencies should be entered into with care, and the contract of service should be reviewed by your lawyer prior to entering into it to identify contingent liabilities that it may entail.
REVIEWS AND ACTION
CLAIM SNAPSHOT The third party asked the insured to transfer a video tape of their children growing up onto DVD format. As this type of work is contracted out to another company, the insured arranged for the video tape to be couriered. The video tape was subsequently lost in transit. The third party threatened legal action unless the tape was returned. The pharmacist had no agreement with the contractor and could therefore be found liable for the resultant loss.
When a spillage occurs, the area should be cordoned off with a sign advising of the potential danger. Spillages should be attended to promptly. Ancillary services; agencies Risks associated with ancillary services will include: expertise to deliver the service registration or qualifications required privacy consent occupational health and safety. These issues arise in the provision of the following common services: ear or body piercing audiometric tests beauty treatments glucose or cholesterol testing.
As a matter of routine, the pharmacy should carry out an operations review (say monthly or quarterly), record issues at variance with standards, and record action taken. Action is vital where a problem is identified.
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SECTION 4
HEALTH & SAFETY

Employers have a non delegable duty to manage workplace health and safety, to consult with staff on health and safety and to minimise risks associated with carrying out work duties.
Challenges Question-and-answer Risk and Quality Snapshot Systems & ergonomics Infection control Workplace stress Housekeeping 25 26 27 28 29 30
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G U I L D WATC H HEALTH & SAFETY
CHALLENGES
Health and safety management is an integral part of the effective operation of a pharmacy. The long hours in which pharmacies operate and the nature of the services provided influence the risk profile.
Establishing a system for identifying, assessing and actioning potential risks. Applying the most effective measures to minimise risk. Managing work practices and the environment to minimise injury and incidents. Training in correct manual handling. Training to minimise the risk and effects of armed hold-up. Training in infection control; correct disposal of biohazards; protective equipment use. Offering immunisation to those at risk of contracting HepA, HepB or Influenza. Sound housekeeping practice to reduce the risk of accident, especially in non-retail areas. Tagging programs for all electrical equipment on an annual basis. Checking all equipment on a regular basis, especially steps and ladders. Management of staff to reduce stress and improve communications; sound OHS management.
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Work through the following checklist to assess how your pharmacy is handling its health and safety.
SAFETY SYSTEMS Is a system used to identify hazards, assess and manage risk? Is action taken when risks are identified? Are basic management records of such actions kept? Is staff consultation formalised? ERGONOMICS; MANUAL HANDLING Are tasks assessed for their ergonomic impacts? Are work stations designed to reduce strain, stretching etc? Can seating and computer equipment be adjusted? Is lighting adequate in the dispensary and in non-retail areas? Is manual handling included in training for induction? INFECTION CONTROL Does infection control form part of induction training? Are gloves and goggles used when handling blood? Are sharps and lancets strictly single use? Is appropriate biohazard disposal used? Are staff immunised against influenza and HepA and HepB? WORKPLACE STRESS Are work breaks scheduled to reduce fatigue? Is communication kept open and non-discriminatory? Is training provided on armed hold-up and response? Are anti-discrimination and anti-harassment policies in place? Are tasks allocated on an equitable basis? Are incidents and grievances documented and followed up? ELECTRICAL Are all electrical goods checked and tagged annually? Are Residual Current Devices (safety switches) in place? Is care taken to separate liquids and electrics? Are computers well ventilated and switched off after hours? Is powerboard use avoided; overloading avoided? HOUSEKEEPING Are non-retail areas (stores, kitchen, office) well organised? Are staff amenity areas adequate (space etc)? Are premises reviewed regularly for issues requiring action? Is ventilation and space adequate for assembling packs?
Q
&
Yes Could improve
A
No
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SYSTEMS & ERGONOMICS

The need from both a legislative and moral perspective to manage the health, safety and well being of staff is not new. Pharmacies need to be able to evidence their management of this risk with clear policies and close consultation. Some of the basic elements follow.
Systems A health and safety policy sets a standard, makes safety a shared concern and demonstrates to staff and to authorities that you have taken your responsibilities seriously. Formal consultation with staff means that a consultation mechanism is in place that ensures communication on health and safety occurs. This may necessitate the nomination of health and safety representatives, establishing designated work groups or an OHS committee. Fitting the tasks to humans, not the other way around is the essence of good work design. The many repetitive tasks in a pharmacy, warrant a detailed examination of workflow and the physical environment.
HAZARD IDENTIFICATION
Unless you are aware of a hazard it is not likely to be managed. Identifying hazards requires a routine and formal review of all aspects of the pharmacys operations.
RISK ASSESSMENT
The dispensing process requires a large number of repetitive movements which can cause physical injury. The following are some of the factors that need to be considered: reach distances to pharmaceuticals, other stock etc. (shelf height and so on) space to carry out tasks height of work stations lighting levels and glare, shadow and reflection factors positioning of keyboard, screen and mouse script positioning for reading posture when standing or sitting work pace and breaks table and bench heights task duration and repetition bending and twisting adjustability of seating, fittings, equipment stock placement (too high for example).
MANUAL HANDLING
Measuring the risk associated with a hazard. This is an evaluation of the likelihood, the severity, and the consequence of an incident, in view of the current controls in place.
RISK CONTROL
By far the most important stage in the cycle is to apply the most appropriate and effective controls to minimise any identified risks.
REVIEW OF CONTROL SYSTEM
The review process determines the effectiveness, relevancy and currency of the controls put into place to manage risk. Ergonomics
MORE THAN MEETS THE EYE!
Pharmacies would consider themselves to be low risk work environments, but on closer examination it can be seen that there are various risks associated with the nature of the business. Low risk doesnt mean no risk, and the purpose of ergonomics is to isolate those work systems and equipment that pose a risk to employees.
RISKS
Manual handling is a common source of injury. For this reason, it is subject to its own regulation. Manual handling risk needs to be assessed, factors include load weight and bulk, task repetition, task duration, postures adopted and employee fitness for the task. The work place and work tasks should be designed so that the frequency and intensity of manual handling tasks are minimised.
The risks associated with poor work design include the loss of productivity and risk of injury or error where employees experience fatigue or become uncomfortable in the dispensary, treatment areas, stores and in any other work areas such as an agency desk, the cash register and the non-retail office areas.
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INFECTION CONTROL
Infection from body substances, mainly blood, is a potential risk where a pharmacy offers ancillary services such as piercing, blood glucose and cholesterol testing.
Blood: the smallest amount counts Exposure to a bloodborne disease and airborne contagion is a potential risk to staff. These diseases include HIV, hepatitis (HBV and HCV), and influenza. Stringent controls are required wherever there are activities that expose staff to this foreseeable risk.
BIOLOGICAL HAZARD ISOLATION
IMMUNISATION
All staff exposed to either airborne or blood borne contagion in the course of their work should be offered a course of immunisation; flu vaccination is advisable given the high exposure to the public and the ill.
SINGLE USE CUPS
Standard precautions include the following: exclusion from treatments and tests if staff have a cut or abrasion which is not completely sealed by a waterproof dressing use of single use surgical gloves, and eye goggles, as standard personal protective equipment when carrying out any procedure where blood may be involved use of single use devices to prick skin and draw blood non-recapping of any device and direct disposal into a biohazard sharps container appropriate disposal of any biohazardous waste and washing of hands. The transfer process must be designed to minimise risk of blood splatter. Controls include: test strips placed flat on a hard surface to minimise risk of their flicking up and spraying blood direct application of blood to test strips.
PERSONAL HYGIENE
If the pharmacy is involved in a methadone program, single use cups should be used and rinsed before disposal in general waste.
DISINFECTION
Where blood or other fluids are spilled, the area should be wiped (gloves and goggles used) and disinfected with 100% strength of a certified disinfectant.
WRITTEN PROCEDURE
The community has a good level of awareness about blood borne disease, and the use of gloves and goggles is understood to be a normal practice in a healthcare services environment, and high standards in this regard would be expected of pharmacy.
There should be written and known procedures to follow for substance isolation with training provided during induction.
POST EXPOSURE CONTROL
There should be a protocol in place and readily accessible. If an incident occurs (such as a sharps, or used lancet puncture or blood splatter in the eye), a specific post exposure procedure should be followed: the area of puncture or access should be thoroughly washed with antiseptic the sharp or source should be placed in a rigid container such as a capped jar the source of the blood should be approached to have a voluntary test the staff member should attend a doctor and supply the suspect source for testing tests should be offered; and counselling too. The entire incident should be recorded and efforts made to reduce the anxiety that the event may have given rise to.
Regular hand washing by those exposed to any contagion can reduce their risk of contamination. Exposure to airborne viruses (eg, those working in a pharmacy at the height of flu and cold season) can be assisted through immunisation in addition to regular hand washing.
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WORKPLACE STRESS
Workplace stress can be a source of claims against employers and a pharmacy must therefore organise its work and activities to reduce stress and show that care was taken in the area of employee wellbeing.
Management of work place stress Managing morale and wellbeing can be a complex area as work may not be the main cause of a persons level of stress. The main issues revolve around induction, work load and organisation, communication, incident management and policy and procedure.
INDUCTION
Claims relating to stress are rising, so pharmacies must adopt human resource practices which will reduce the causes of stress and demonstrate management care, especially in the area of discrimination, harassment and response to incidents and grievance.
For this obvious area of exposure the pharmacy should have training in place, and set procedures to follow in the event of armed hold-up. Incident preparation and post incident management is vital for exposed staff whose recovery and response to such an event can be significantly influenced by its management. To do otherwise, when armed hold-up is a foreseeable risk in pharmacy is neglecting your duty of care.
POLICY AND PROCEDURE
A prepared induction makes it easier for employees to settle in, and reduces anxiety. It should equip them with the information, training and instruction that allows them to conduct their tasks competently and safely.
It may seem like overkill for a small team, but failure to have specific policies on discrimination WORK ORGANISATION harassment Tasks should be distributed equitably, with reasonable work load appropriate work breaks taken by all staff to minimise fatigue. A management plan should staff breaks be in place for staff working late. Provide the may lead to claims. As an employer, you appropriate controls to maximise staff safety must make it clear what standards of during late hours, and avoid, if possible, staff behaviour are not tolerated. The best place and time to do this is during a formal working alone. induction, but should also be reinforced at Avoid placing staff in positions of risk, appropriate intervals. particularly carrying cash.
COMMUNICATION
Establish a culture and supporting systems for open communication to avoid claims of victimisation or discrimination. Ensure that a health and safety representative or a health and safety committee is in place to address health and safety concerns.
CRITICAL INCIDENT MANAGEMENT
Extraordinary incidents such as an armed hold-up should receive a professional response in the form of counselling.
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HOUSEKEEPING
Good housekeeping makes the workplace more comfortable and productive, and helps with reducing risk. A stitch in time literally saves nine in these areas.
SECURITY AND SURVEILLANCE
Reducing opportunity for mishap Electrical hazards arise in several places throughout the pharmacy and require management consistent with legislation. Because of the severity of a mishap with electricity, extra caution is required in this area. In a busy pharmacy serving the customer takes priority. The result can be a retail area, a store room, office or tea room that can at times become untidy and cluttered, creating a risk to work place health and safety.
SLIPS, TRIPS AND FALLS
Because pharmacies are open for long hours and have both permanent, part time and locum staff, some thought needs to be given to security and surveillance in non-public areas.
KEYS TO GOOD HOUSEKEEPING
Because of the high level of traffic and long hours which pharmacies experience, slips, trips and falls are a common source of claims. A messy work environment creates a foreseeable injury risk and with regard to public liability, dilutes defensibility should any incident occur .
EVERYTHING IN ITS PLACE
develop checklists (which are actioned and then filed) for monitoring the pharmacys housekeeping incorporate specific tidying up tasks in job descriptions devise a specific regime for dealing with waste and ensure that any biohazard waste is disposed of correctly inspect all equipment regularly, including equipment not in public use or view ensure that care is exercised in organising store rooms. Poor housekeeping can be responsible for injuries, errors, or fires.
MANAGEMENT OF ELECTRICAL GOODS
CLAIM SNAPSHOT An employer was fined in a landmark OHS case concerning occupational overuse injuries. Following the court ruling the employer was fined approximately $16,000 for a breach in their duty of care to provide a work environment that was safe and posed minimal risk to the health of employees.
Ensuring that the environment is well organised reduces the risk of mishap especially for new, unfamiliar staff. The nonretail areas should be as organised a space as the dispensary; and the same care used in the pharmacy regarding security and safety should also apply.
STAFF AMENITIES
Staff amenities must be of a standard which will not give rise to grievance on the part of a disgruntled employee. Space is at a premium in most pharmacies, but room must be made for staff amenity. Note too that upkeep is important: a spill on a hard surface in a tea room is as great a risk for a claim as a spill in the pharmacy entrance.
Pharmacies have a large power load and operate a range of electrical equipment Risks include: electrocution fire, especially out of hours damage to equipment flash burns.
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HOUSEKEEPING (continued)
TAGGING
All electrical equipment should be checked and tagged by a qualified electrical tradesperson at least every 12 months. This program will reduce the risk of fire from electrical faults, as well as the risk of personal injury.
COMPUTERS
The switchboard should also have protection from electrical surges which, although infrequent, can destroy vital equipment such as vaccine refrigeration and computers.
THERMOGRAPHIC SCAN
Computers can cause electrical fires if left on and unattended. The risk rises if ventilation around a computer is poor.
RESIDUAL CURRENT DEVICES (RCD)
Having an electrician conduct a thermographic scan of your switchboard is an effective means of identifying heat build up and may possibly prevent an electrical problem which could result in fire.
All outlets and equipment should be protected by RCDs (safety switch) which will respond to earth leakage.
PUBLIC LIABILITY AND OHS CHECKLIST

YES Resolve (or remove) any obstructions/protrusions Stable fittings/fixtures Sharp edges on fixtures Merchandise stacked/stored safely Sturdy/safe customer seating Sturdy ladder/steps Internal areas always well lit External area well lit after dark Floor even and in good condition NO Non-slip floor surface Good ventilation and heating First Aid kit present/well stocked Clean staff facilities Emergency contact number displayed Safety switch protection on power points Appliance cords in good condition Emergency exits accessible and visible Fire extinguishers present/serviced YES NO
Reference: Quality Care Pharmacy Planning, 2nd edition
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SECTION 5
PRIVACY CONTROLS
A good measure of the effectiveness of your privacy controls and the pharmacys sensitivity to privacy is to ask the question of any action: would I personally be happy if this happened to me?
Q
Yes
Privacy check Does the pharmacy have a policy on privacy? Does the pharmacy train new staff on privacy? Is consent sought before information is divulged to third parties?
&
Could improve No
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G U I L D WATC H PRIVACY CONTROLS
LITIGATION RISKS
Privacy has become a large social issue with the passing of legislation guaranteeing rights to privacy and consequent consumer awareness of privacy rights.
Main principles The main principles concern the sharing of information with third parties where the patient has not provided consent for you to do so. This is not easy to manage because in many instances family members and partners provide care or run errands. A great deal will depend upon judgement but there are obvious actions that should be avoided.
PUBLIC AREAS
Electronic communications Sending health and medical records via facsimile (for example HMRs) could place a patients information in view of others. Pharmacies should consider the adoption of the Public Key Infrastructure, (PKI) a combination of procedures and technology providing security and confidentiality for electronic business. The PKI is the framework adopted by the Australian Government and health sector to provide authentication and confidentiality for online transactions. It is a secure and confidential method using digital certificates and authentication before data is released. It is being used to transfer information between GPs and Specialists, practitioners and hospitals. Pharmacy could adopt this as a means of further minimising the risk of confidential / sensitive information being read or accessed by those, other than for whom the information is intended. ( ref : www.hesa.com.au )
CONCLUSION
Note that people often maintain some secrecy about their ailments and may feel aggrieved if the release of unauthorised personal information leads to embarrassment or interpersonal conflict. Managing privacy is a statutory obligation which must be given due regard in managing the pharmacy.
Private information should be kept out of view of public areas.

PHONES
Discussions about patients on speaker phone are risky as the communication may be overheard by third parties.
MESSAGES
Messages about scripts ready for collection, or issues associated with the script should not be left with friends or relatives. The patient may not have wanted to share information about a condition.
OTHER CLINICIANS
Where advice and information is to be shared, it is appropriate to seek the patients consent before discussing the medication with another clinician.
PUBLIC COMMUNICATIONS
All staff should be trained at induction on the inadvisability of discussing patients with other staff, particularly in public areas, or worse still, outside the pharmacy environment.
Privacy issues are centre stage and require careful judgement and skill. As a general rule, always ask a patient before divulging information to a third party and, if possible, note their response on the file. Try to counsel patients away from others, in an area providing relative privacy. Train staff, especially new staff, on the importance of customer privacy and set clear limits on what is to be said at the counter in relation to any patient. A clear policy in regard to confidentiality should be developed. Each staff member should sign an undertaking in relation to confidentiality.
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SECTION 6
INCIDENTS & CLAIMS

Accidents, incidents and near misses will occur; the issue is how they are dealt withand this requires some forethought and training.
Q
&
Yes
Claims check
Does the pharmacy train new staff on response to issues? Does the pharmacy maintain a log of incidents/accidents?
Could improve
A
No
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G U I L D WATC H INCIDENTS & CLAIMS
LITIGATION RISKS
Incidents, complaints and claims require a structured response so that cases are treated equitably for all parties. Guild staff are trained to handle the communication issues for you.
Accidents and incidents The pharmacy should maintain a good record of all incidents and accidents including an account of what was done to remedy the situation. This log is vital to the defence of a later claim where negligence is suggested. Incidents will include dispensing errors (discussed below in detail) as well as any public liability-type claim. In all cases, it is wise to contact your insurer and allow the matter to be handled professionally. Dispensing errors: a response When an error may have occurred it is essential to follow the procedure outlined below. 1 2 3 6 Determine whether any of the wrong drug or dose had been ingested. Has any harm been suffered? Has any expense been incurred? Contact the prescriber. Do not offer compensation This may be regarded as an attempt to bribe your way out of trouble. Do not mention your insurance cover or the Pharmacy Board, as this will only sow the seeds of opportunity. 7 At all times remain calm, sympathetic and co-operative. Advise that you will investigate how this incident occurred. Obtain a phone number for any follow-up.
As the law has evolved the complexity of dealing with claims has also increased so it is very important that policy holders follow the steps advised here in responding to a matter that has arisen.
8 Telephone PDL/Guild Insurance and notify them of the problem. You will be advised of what further action to take. It is When presented with a complaint, ensure important that you report any incident the matter is handled by the pharmacist. where the wrong drug or wrong dose has Show concern and willingness to correct been ingested, as a claim could well be any error. lodged at a future date. Check out the alleged error and if 9 Record the details and all relevant established replace the offending item information in your diary. These notes may immediately. be extremely important in any subsequent defence of a claim. If it was dispensed at another pharmacy, check with that pharmacy and replace if 10 If, after the patient has left the pharmacy, possible. Take care not to compound the you suspect that an error has been made, problem. Retain the evidence if possible. act speedily to correct the problem, without causing any unnecessary alarm. An apology couched in the right way will
not constitute an admission of liability. You 11 When a complaint is initiated by should use either of the following which correspondence it is most important that are two ways of apologising without you do not reply without first asking admitting liability. advice from PDL/Guild Insurance. Do not put anything in writing without advice from I am sorry this has happened. PDL/Guild Insurance. I know this has caused you 12 If confronted by an investigating officer concern/pain/anxiety. seeking information relating to drugs 5 Show empathy towards the patient. This dispensed for a patient who has died or gives them the opportunity to vent their whose health has been compromised, it is feelings so you might learn where you recommended that PDL/Guild Insurance truly stand. be contacted immediately so that legal advice can be provided.
35
SECTION 7
RISK HORIZONS
Sections 1 to 6 of this document have presented controllable risks where action and planning can reduce the likelihood or severity of an adverse event. But some risks are far less easy to respond to and control. These are risks which arise from the operating environment and tend to be larger events which may impact the entire community, not just your pharmacy. They may be catastrophes.
The obvious examples of these unlikely but not impossible events include a serious health crisis such as an influenza pandemic or a weatherrelated event which seriously disrupts business and supply lines. These risks "on the horizon" will, hopefully, never materialise. But risk management must make some reasonable provision for them. Obviously, the resources devoted to this must be in proportion to the severity of consequences and to the perception of likelihood. CONTINUITY PLANNING This is the name for the process of planning for "the unexpected"; the "horizon risks". For a pharmacy, the objective is to minimise the disruption, and to enable the business to refocus and regroup after the event has climaxed and life 'returns to normal.The key is to be mentally ready and to have some specific approaches agreed. Taking a healthcare crisis as an example, here are some of the things to be considered:
Will the business trade during the crisis, or on reduced hours? What is the minimum staffing required and what are the core skills required? How will supply be managed and maintained? What is the policy regarding sick leave and immunisation and precautions for staff in the event of a health crisis? How is communication going to be handled? Customers, staff, medical practitioners, suppliers and government agencies will be seeking information. How will the financial impacts be managed? The key is achieving awareness and having some level of planning in place. By definition, it is a difficult area for a pharmacy to manage. A continuity plan may, however, reduce the stresses associated with such a crisis and improve the ability to regroup and rebound.
36
GuildWatch is produced by Guild Insurance Limited
Risk Management Overview AS4360
Establish the Context
Communicate and consult
Identify risks
Analyse risks
Evaluate risks
Treat risks
PRODUCED BY: GUILD INSURANCE LIMITED ABN 55 004 538 863 AFSL No. 233791 40 BURWOOD ROAD HAWTHORN VICTORIA 3122 PHONE 1800 810 213 www.guildifs.com.au Guild Insurance Limited 2007
Monitor & review

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G U I L D WAT C H

GUIDE TO GOOD DISPENSING

SECURITY & LOSS

HEALTH & SAFETY

David Roddis Group Risk Manager

INCIDENTS & CLAIMS

GUIDE TO GOOD DISPENSING

G U I L D WATC H GUIDE TO GOOD DISPENSING

Question-and-answer Risk and Quality Snapshot

G U I L D WATC H GUIDE TO GOOD DISPENSING

ERRORS & SOLUTIONS

G U I L D WATC H GUIDE TO GOOD DISPENSING

ERRORS & SOLUTIONS (continued)

G U I L D WATC H GUIDE TO GOOD DISPENSING

ERRORS & SOLUTIONS (continued)

COMMON SOUND-ALIKE/LOOK-ALIKE DRUGS

RISK CONTROL STEPS IN DISPENSING

SECURITY & LOSS

G U I L D WATC H SECURITY & LOSS

Question-and-answer Risk and Quality Snapshot

G U I L D WATC H SECURITY & LOSS

CASH & NEGOTIABLES

G U I L D WATC H SECURITY & LOSS

G U I L D WATC H SECURITY & LOSS

G U I L D WATC H SECURITY & LOSS

THEFT; FRAUD (contd)

G U I L D WATC H SECURITY & LOSS

G U I L D WATC H PUBLIC LIABILITY

Question-and-answer Risk and Quality Snapshot

Yes Could improve

G U I L D WATC H PUBLIC LIABILITY

G U I L D WATC H PUBLIC LIABILITY

LAYOUT AND SERVICES

G U I L D WATC H PUBLIC LIABILITY

LAYOUT AND SERVICES (continued)

HEALTH & SAFETY

G U I L D WATC H HEALTH & SAFETY

Question-and-answer Risk and Quality Snapshot

Yes Could improve

G U I L D WATC H HEALTH & SAFETY

SYSTEMS & ERGONOMICS

G U I L D WATC H HEALTH & SAFETY

G U I L D WATC H HEALTH & SAFETY

G U I L D WATC H HEALTH & SAFETY

G U I L D WATC H HEALTH & SAFETY

PUBLIC LIABILITY AND OHS CHECKLIST

Reference: Quality Care Pharmacy Planning, 2nd edition

Question-and-answer Risk and Quality Snapshot

G U I L D WATC H PRIVACY CONTROLS

Private information should be kept out of view of public areas.

INCIDENTS & CLAIMS

Question-and-answer Risk and Quality Snapshot

G U I L D WATC H INCIDENTS & CLAIMS

GuildWatch is produced by Guild Insurance Limited

Risk Management Overview AS4360

Establish the Context

Communicate and consult

Monitor & review

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