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Delivery drivers involved in 5% of 'dispensing errors' over 3 months

NPA: Posting medicines through a letterbox should be a last resort
NPA: Posting medicines through a letterbox should be a last resort

Delivery drivers were involved in 5% of dispensing errors reported to the National Pharmacy Association (NPA) in the first three months of 2018.

The most common errors included medication delivered to the wrong address and standard operating procedures (SOPs) for delivery drivers not – or incorrectly – followed, the NPA said in its latest medication safety officer report.

One incident of medication delivered to the wrong patient “due to similar-looking and/or similar-sounding names” led to hospitalisation, the NPA said in its report, published last week (May 10).

The NPA highlighted delivery driver issues as one of the “common themes” and “frequent errors” reported between January and March 2018.

“Another incident occurred whereby a temporary delivery driver posted medicines through the letterbox of a patient not at home. The delivery driver had not read the pharmacy SOPs and not gained consent from the patient,” the NPA added.

NPA chief pharmacist Leyla Hannbeck pointed to the organisation’s “top tips for minimising patient safety incidents” in her letter to pharmacy superintendents sent with the latest report, which includes advice on “considering posting medicines through a letterbox” (see more below).

While medicines, including controlled drugs, “legally can be posted, posting medicines through a letterbox should be a last resort”, the NPA stressed.

Empty bottle of methadone

Aside from delivery driver issues, for the second three-month period in a row, dispensing errors involving methadone were “commonly reported”, making up 4% of errors reported, the NPA said.

“In one example, an empty bottle of methadone was found in another patient’s bag, raising patient safety concerns.”

The NPA reported “many incidents” of controlled drugs being dispensed in the wrong formulation. It used the examples of buprenorphine tablets being confused with the oral lyophilisate form, and tramadol capsules being confused with the modified-release formulation.

Other trends highlighted in the latest report included medicines dispensed in error because of confusion over brand names, including Vensir and Viazem, and Zestoretic and Zestril, the NPA said.

Post-dated prescriptions

An example of “other interesting errors” over the three-month period noted by the NPA included “cases where post-dated prescriptions were dispensed and handed to patients before they were due”.

“Pharmacy team members must ensure they are more stringent when prescriptions are received to ensure [they] meet the legal requirements,” the NPA stressed. “If post-dated prescriptions are received, this should be clearly highlighted and segregated from other prescriptions, until it is due.”

“Work and environment factors” continued to be the main contributors to patient safety incidents in the three months to March, accounting for 47% of errors, the NPA said.

The majority – 52% – of all incident reports to the NPA continue to involve “no harm” to the patient, while 34% were reported as “near misses”, it pointed out.

Read a full copy of the NPA’s report for January-March 2018 here.

The NPA’s advice when posting medicines through the letterbox

  • An SOP should be in place for the delivery of medicines, including a process for posting the medicines through a letterbox
  • The indemnity insurer of the pharmacy should be contacted to ensure the process is covered if an incident occurred
  • Patient consent/a letter of authority should be sought to ensure the patient authorises their medicines to be posted through the letterbox and that there are no pets/young children/vulnerable patients present at the property.

Source: NPA patient safety quarterly report, January-March 2018

8 Comments
Question: 
Do your pharmacy SOPs include a process for posting medicines through a letterbox?

Pharmacist Since 1986, Community pharmacist

Is there one rule for Community Pharmacy, and another for P2U?

GPhC Inspectors ask to see the delivery driver audit sheets with patient signatures confirming delivery. This cannot happen for P2U, as they use  3rd party delivery agents (Royal Mail).

Community pharmacy deliveries that are unsuccesful are returned to the pharmacy for safe storage (CD cupboard, fridge, or the temperature controlled safe haven of the dispensary). Not if you are P2U, when the medication presumably resides in a Royal mail depot if undelivered.

Pharmacies must dispense with "with reasonable promptness" according to the terms of service. Not if you are P2U, who have an online disclaimer whereby "Royal Mail may not meet expected service levels. In this situation please allow 7-10 days from dispatch before contacting us".

Pharmacies must abide by the NHS Brand Guidelines when using the NHS logo "a pharmacy cannot use the NHS logo on pharmacy promotional or advertising materials". Not if you are P2U, who continue to use the NHS logo on their envelopes and letters advertising their non-NHS managed repeat service.

Murphys Law: things will go wrong in any given situation, if you give them a chance. Medication posted through a letterbox by 3rd party contractors on the scale of P2U provides many such "chances" for error.  Does it really need a serious incident to happen to ensure all pharmacies adhere to the same standards?

Uma Patel, Community pharmacist

Deliveries are pushed through the letterbox because the patient is shopping at local Superstore or is at the hairdresser!

Keith Sykes, Community pharmacist

No signature, No ID, No medicine, we can redeliver when convenient or collect from shop. 

Brian AUSTEN, Administration & Support

I cannot understand how it is acceptable to post drugs through a letterbox. Any risk assessment by a health and safety assessor would come to the conclusion the best way to minimise risk is to remove the hazard. Don't post through letter box but get signature from the patient or the notified representative. Patient safety, not commercial convenience should be the focus.

Richard MacLeavy, Non Pharmacist Branch Manager

P2U Delivery SOP

1. Ensure written consent is obtained from the patient. To help gain consent make all marketing material appear as if using P2U is an NHS instruction not a choice.

2. Also remind potential patients that using P2U over a community pharmacy saves the NHS money. Shame I couldn't remember how exactly when the advertising standards authority asked. 

3. Try to make the delivery within a prompt timescale of receiving the prescription unless of course its christmas time when an extra 2 weeks will be taken.

4. Make all deliveries using Royal mail. This guantees to ensure that deliveries are only made by healthcare experts familiar with this SOP. It also ensures adequate storage conditions of medicines are maintained.

5. Don't bother knocking on the door, thats what letterboxes are for. Besides if the patient is in hospital they will be glad of a few extra dossett boxes when they get home.

6. Bulky items and controlled drugs should be strategically placed behind plant pots, for safety reasons.

Pharmacist Since 1986, Community pharmacist

Very amusing, but sadly true. It is as though the "authorities" are uninterested in challenging P2U.

Adam Hall, Community pharmacist

Probably hidden away at the bottom of the terms and conditions will be something about P2U accepting no liability or responsibility for incorrect deliveries

A.S. Singh, Community pharmacist

Makes me wonder what P2U would do when they deliver 300k items and the postman gets it wrong. I bet their legal team would pin it on the postman

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