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NPA Essential


The most common errors reported to the NPA in 2017 were ‘wrong drug’ (24%) and ‘wrong/unclear dose or strength’ (24%) errors.

The top three ‘wrong drug’ errors reported in 2017 were:

  • Amlodipine/amitriptyline
  • Atenolol/allopurinol
  • Pregabalin/gabapentin

The top contributing factor reported in 2017 was ‘work and environment’ factors (39%) and ‘no harm’ was the highest reported outcome (67%) in 2017.

Patient safety incidents associated with dispensing opioid medicines is a recurring and prominent issue, as highlighted by the NRLS alert released in 2008. The NPA developed a patient safety resource for dispensing opioids, including opioid dispensing top tips, in order to reduce opioid related patient safety incidents. Valproate and the associated risks of birth defects due to in-utero exposure remain a patient safety priority to the Medicines and Healthcare products Regulatory Authority (MHRA) – the NPA developed a valproate dispensing checklist to assist pharmacy teams with all patient safety aspects when dispensing valproate for pregnant females or women of childbearing potential. NPA’s Chief Pharmacist Leyla Hannbeck raised concerns around antibiotic prescribing errors, following a number of reports she received.

To assist pharmacy teams to remain vigilant of antibiotic prescribing errors and provide guidance on how to manage such errors, she highlighted a suggested checklist for use when performing a clinical check, available on the NPA website, along with guidance on use of appropriate clinical resources and raising concerns with prescribers.

Quarter 4 of 2017 showed an increase in the number of errors involving dispensing of combination products against generic and branded prescriptions – products with two or more active ingredients, in particular eye preparations. Therefore, the NPA has developed the ‘Eye products identification checker’ resource, which is designed to support pharmacy teams in dispensing and accuracy-checking generically written prescriptions for eye products. The resource is comprised of two parts; part 1 – licensed eye products and part 2 – eye devices.

The resource also includes the drug class, generic name/active ingredients and strength, brand name (where applicable), formulation, preservative content and shelf life after opening for each product. Safety incident reports submitted to the NPA provide us with vital information and allow us to analyse national trends and share learnings from patient safety incidents on a national level. Community pharmacies in England and Scotland are encouraged to submit patient safety incident reports via the NPA website. For pharmacies in Northern Ireland, reports should be submitted to the Health and Social Care (HSC) Board anonymous reporting form and in Wales, patient safety incidents should be reported via the National Reporting and Learning System (NRLS).

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NPA Essential