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.