NPA Essential 
Quarterly summary of patients safety incidents
Medicines safety update – how to minimise the risk of errors
Leyla Hannbeck is the Medication Safety Officer for independent pharmacies. Here is a summary of her latest report:
The main types of medication incidents reported were:
- ‘Wrong drug/medicine’ supplied (31%)
- ‘Wrong/unclear dose or strength’ labelled/supplied (27%).
The most important factor for reported errors was found to be:
- ‘Medicines with a similar looking or sounding name’ (61%)
- ‘Work and environment’ factor was cited as the main contributing factor for the reported errors (61%)
- The majority of reported errors (86%) involved either a near miss (30%) or an error causing no harm to the patient (56%)
Medicines with similar names most commonly involved in the ‘wrong drug’ errors include:
- Allopurinol/atenolol
- Amitriptyline/amlodipine
- Atenolol/amitriptyline
- Chlorphenamine/chlorpromazine
- Enalapril/escitalopram
- Metoprolol/metoclopramide
- NovoMix/NovoRapid
- Paracetamol/co-codamol
- Pravastatin/paroxetine
- Propranolol/pravastatinÂ
Medicines most commonly involved in ‘wrong strength’ errors:
- Allopurinol
- Amlodipine
- Atorvastatin
- Gabapentin
- Lansoprazole
- Metformin
- Pregabalin
- Ramipril
- Sertraline
- Simvastatin
Medicines most commonly involved in ‘wrong formulation’ errors:
- Cefalexin tablets/capsules
- Methadone/methadone sugar free
- Montelukast chewable tablets/granules
- Paracetamol tablets/soluble tablets
- Prednisolone tablets/enteric coated tablets
- Ramipril tablets/capsules
- Salbutamol breath actuated inhaler/metered dose inhaler
- Venlafaxine tablet/modified release tablet
Tips for minimising risk/general action points:
- Add a note on the PMR system highlighting an unusual form or strength of a medicine received regularly by a patient, especially if an error has occurred previously
- Ensure robust date checking procedures are being implemented and check dates of all medicines as they are dispensed, including those just received from the wholesaler
- Keep all surfaces clear of clutter
- Separate products with similar names on dispensary shelves
- Consider using brightly coloured shelf edge labels
- Take a mental break when dispensing/checking prescriptions
- Take extra care when checking prescriptions dispensed by inexperienced/trainee staff
- Ensure that split packs are clearly marked and, when dispensing, check the contents to ensure the correct item is in the pack
- For insulin, show the box to the patient before handing over
The NPA has published “Dispensing process: best practice†to provide guidance for pharmacists/ pharmacy owners when reviewing dispensing SOPs.
For further information contact the NPA Pharmacy Services team on 01727 891 800 or email pharmacyservices@npa.co.uk.
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