The NPA shared the data in its latest medication safety officer (MSO) report, published last week (October 24).  

The report also found that the number of patient safety incidents reported in April, May and June decreased 45% compared to the first three months of 2020.

This drop “may be due to the increased workload and pressure on pharmacy teams due to [the] COVID-19 pandemic, whereby pharmacy teams may not be prioritising reporting of patient safety incidents,” the MSO report said.

The report included an “important reminder” for pharmacy teams to “continue to report, investigate and analyse patient safety incidents” in light of the reduction in  incidents flagged.

A spokesperson for the NPA, which described the decrease in reporting as “significant”, told C+D yesterday (October 27) that it will “continue to raise awareness of the importance of reporting incidents”.

Types of errors

Dispensing errors accounted for 83% of all reported incidents, an increase of two percentage points on  the previous quarter’s figure.

Delivery and collection errors made up 10%, up 3 percentage points when compared with the first quarter of this year.

Medication errors constituted 67% of errors reported – a seven percentage point increase on the previous quarter. Of these, 30% were “wrong drug/medicine” incidents, 25% wrong strength”  and 12% “wrong formulation” incidents.

Overall, 94% of patient safety incidents originated from pharmacy, while 2% came from prescribers.

Contributing factors

“Work and environment factors” (40%) were the main contributor to patient safety incidents during the quarter, the NPA said. This is up five percentage points from the first quarter of 2020.

“This category includes time pressures, understaffing and poorly organised working environments,” the NPA said.

the work and environment  factor was followed by look-alike sound-alike (LASA) errors (21%). The majority of these (6%) involved amlodipine and amitriptyline – however, this was down two percentage points  on the first quarter of the year.

Gabapentin and pregabalin featured in 3% of all LASA errors reported, and the NPA stressed the importance of the medications being “separated out in the dispensary with clear reminders for staff to double check the item they pick”.

COVID-19 impact

While the incident reporting platform did not allow the pandemic to be selected as a contributing factor, the NPA said that 10% of incidents reported “included COVID-19 work pressures as other important factors contributing to incidents”.

The NPA included learning points for pharmacy teams in the report, highlighting  situations where the pandemic may increase the risk of a patient safety incident occurring.

It explained that the examples can be used to “help pharmacy teams reduce incidents occurring due to the pandemic”. Doing so is of  “particular importance due to the increase in demand in community pharmacies under the current climate,” the NPA added.