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/pravastatin 

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.