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/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.

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