Making a mistake: IRMIS

Last updated: Wednesday, March 08, 2023

The Incident Reporting in Medicines Information Scheme (IRMIS) is a secure, password-protected database. Its purpose is to raise awareness amongst hospital pharmacy staff of the common reasons for errors and near misses related to providing advice and information about medicines, and to look at ways to avoid future incidents. Managers of Medicines Information centres can report errors and near misses identified within their service.

The IRMIS scheme is intended to complement, but not replace, existing incident recording systems within each Trust. 

Here are some examples of recurring factors identified via IRMIS that seem to increase the risk of making mistakes when problem solving:

Risk factors
Ways of reducing risk
You are busy, rushed, feel pressurised for a quick answer, or are subject to lots of interruptions.
Recognise that when you are in situations like this you are more likely to make a mistake. Try to step back and give yourself enough time to consider the question and research an answer properly. Prioritise the demands made upon you, and ask for help if you are swamped.

Calculation errors
Double-check all calculations yourself, no matter how simple they seem. If necessary, get the calculation checked by an independent person (without telling them what your initial answer was!).

Similar-sounding drug names
If in doubt, ask for all drug names to be spelt out by the person you’re dealing with, especially OTC and alternative therapies. Or look at the original packaging yourself if you can.

Answering the wrong question
After the person you’re dealing with has told you their problem, summarise it for them to make sure you've got it right. And when answering it later, your conversation or e-mail should start with confirmation of what the question was.

Your personal knowledge is not up-to-date
Regularly review your knowledge by undertaking training, using a current awareness service such as that run by NICE, reading journals, and networking with colleagues.

You don't use a resource properly and miss information or misinterpret it
Spend time learning to use information resources properly or get training, don't just plunge in.