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HRT stock shortages could be contributing to pharmacy errors

HRT preparations are a common source of 'look-alike, sound-alike' errors
HRT preparations are a common source of 'look-alike, sound-alike' errors

The daily pressure of sourcing HRT products could be contributing to the number of patient safety incidents reported in pharmacies, the NPA's medication safety officer has said.

Speaking exclusively to C+D yesterday (April 30), Leyla Hannbeck said: “Dealing with ongoing medicine shortages on a daily basis puts additional pressure on pharmacy teams at a time when the pharmacy workload is already very significant.”

She suggested current shortages of certain hormone replacement therapy (HRT) products could be responsible for these preparations becoming one of the most common causes of ‘look-alike, sound-alike’ errors in the first three months of 2019, “as patients are being switched to alternative preparations in the interim”.

“HRT preparation errors included: Elleste Solo and Elleste Duet; Femoston and Femoston-conti; and Kliofem and Kliovance,” Ms Hannbeck revealed in her latest medication safety officer (MSO) report last week (April 25).

Yesterday, C+D reported that HRT patches FemSeven Conti and FemSeven Sequi are not expected to reenter the supply chain until early 2020.

Read what other common ‘look-alike, sound-alike’ errors were reported in the first three months of 2019.

Time pressures

There was a 29% increase in patient safety incidents reported in January-March, compared with the final three months of 2018. “Work and environment factors” remained the main contributor, accounting for 34% of all patient safety incidents reported to the National Pharmacy Association (NPA), Ms Hannbeck said.

She listed both “time pressures” – resulting in pharmacists and pharmacy staff “rushing” to complete prescriptions – and pharmacists being “distracted” by questions from staff while checking prescriptions, as examples of “work and environment factors” contributing to incidents.

“Inappropriate skill mix”

As seen in the final three months of 2018, staff shortages had resulted in an “inappropriate skill mix” in a number of pharmacies, which contributed to the patient safety incidents reported in January-March, Ms Hannbeck said.

“Due to increased staff turnover within pharmacy teams – mainly dispensing assistants – pharmacists are having to self-check more prescriptions,” she told C+D yesterday.

Even when new staff join the pharmacy, they need to undergo training, “which takes time”, she added, meaning pharmacists continue to self-check while the new team members get up to speed.

Emergency MDS supply pressures

In one incident which Ms Hannbeck described as typical of a “common error”, a pharmacist was pressured by a patient’s carer to supply an emergency monitored dosage system (MDS) due to “time constraints”. The prescription had not been sent from the GP on time and the patient had run out of their medicines, so the pharmacist dispensed one week’s supply.

Once the prescription was sent to the pharmacy, the pharmacist noticed it contained changes to the patient’s medicine. By this time, the patient had taken the medicines from the morning and afternoon slot, but was not harmed.

Read a full copy of Ms Hannbeck’s report for January-March 2019.

Tips for emergency supplies

  • A pharmacist should always use their professional judgement and clinical appropriateness when considering whether to make an emergency supply to a patient or not
  • Even if a request comes from a carer, the pharmacist should attempt to interview the patient or consider an interview over the telephone to gather relevant information. Where a pharmacist is unable to speak directly to the patient, professional judgement should be used, as other options (such as contacting the GP surgery) may need to be explored
  • Refer to the NPA's emergency supply legal and practical guidance.

Source: NPA medication safety officer (MSO) report January-March 2019

Read C+D’s coverage of the other “common concerns” Ms Hannbeck flagged in her latest MSO report.

How are medicine shortages affecting your pharmacy workload?

V K P, Community pharmacist

has the NPA spoken to the BMA to understand what is so difficult for the GPs to turn around repeat prescriptions within 24 hours rather than stipulating 48 hours and issuing the prescription after 96hours??? what is it that they do for 47 hours and 55min before signing of the prescription and sent to the pharmacy by EPS on the 48th hour. where all the reviews were not done on an ongoing basis right up to the point of request from the pharmacy, what difference would it have made for the GP to send the prescription through and wait to do the review for when they were in the mood for it??

the emergency supply should be banned all to is just an unpaid burden on the pharmacy. 

Just like Michael has elaborated, what bank gives you a fiver by walking and saying " give me £5, my employer has not paid me on time and I require £5 for my next loaf of bread. what will NPA advice the bank-  in the person safety give them the £5 at your own risk. the bank will tell you to get out faster than it took you to walk in to the bank.

how is the princple different to when it comes to the pharmacy sector? if you dont gice the emergency supply you have to justify it to the NPA, and if you do give it, then justify it to the GP. what the hell do you want us to do??? all this psycological harm to the pharmacist but it doesnt matter, they are not patients. they have committed the crime of being a GPhC registered pharmacist and have waived off all their human rights.


Michael Achiampong, Community pharmacist

I am really concerned to read that a pharmacist colleague was pressured by a "patient's carer" to supply an emergency MDS. Whilst not being privy to the actual situation, it is a worrying incident. Thank goodness the patient was not unduly harmed. However, the situation could have been the other way around!

I am grateful for the NPA tips however, pharmacists must not be afraid to say "no" to emergency supply requests. It is often more hassle than it is worth. We're generally in this vocational profession to help people, but sometimes, emergency supply requests feels like asking your bank to lend you a fiver for 72 hours!

This incident is a timely reminder for pharmacist colleagues to remember that we're practising under The Medicines Act 1968 etc and that no matter how much the public pressurize you due to "time constraints" it is much better to do the right thing and delay supplyin the emergency MDS until you have written assurance from the GP surgery or hospital that a new (amended) Rx is on its way.  Easier said than done, but the risks of  things going wrong have to be considered as well as your professional indemnity and reputation.

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