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NPA: 'A lot' of errors occurring during 'handing out' process

NPA: Incidents of patients receiving the wrong medicine increased 17% this quarter
NPA: Incidents of patients receiving the wrong medicine increased 17% this quarter

Approximately 50% of the patient safety incidents reported to the NPA in the three months to September involved mistakes as medicines were handed out to patients.

When the NPA asked pharmacists to specify where in the dispensing process errors were occurring, it identified that “a lot of mistakes happen...when the patient comes to collect their medicine”, National Pharmacy Association (NPA) director of pharmacy Leyla Hannbeck told C+D today (November 8).

She would not give details of the number of “handing out” errors in previous incident reports, but said these errors were previously categorised “more broadly”.

According to the NPA's latest Medication Safety Officer (MSO) report, incidents reported during the “handing out” process included: fridge items – “especially insulin” – handed over to the wrong patient; staff picking medicines based on the labels, rather than the prescription; and patients with similar sounding names receiving the wrong medicines.

Patients receiving wrong medicine

There was a 17% increase in reports of patients receiving the wrong medicine, compared with the error reports received between March and June, including “several errors” involving prescriptions being processed for family members at the same addresses, the NPA said last week (October 31).

It also noted reports of standard operating procedures not being followed by new pharmacy team members and listed “education and training” as one of the main contributors to patient safety incidents, accounting for 13% of all errors reported to the NPA in the three months to September.

“Although there was a slight reduction of patient safety incidents reported” from July to September compared with the three months to June, “the total number of reports remain consistently high”, Ms Hannbeck said in her letter to superintendents.

OTC sales

In another “interesting” error noted by the NPA, a pharmacist discovered that at least six boxes of 30/500mg co-codamol tablets had been mistakenly sold over the counter in place of 8/500mg tablets.

“Trying to rectify the error, the pharmacy put a sign on the counter asking any patients who bought 30/500mg tablets to return them back to the pharmacy as soon as possible,” the NPA said.

Metronidazole instead of nitrofurantoin

The two most common errors reported continue to be “wrong/unclear dose or strength”, accounting for 27% of all patient safety incidents, and “wrong drug/medicine”, accounting for 26%.

Allopurinol and atenolol, amlodipine and amitriptyline, and gabapentin and pregabalin, were among the commonly mistaken medicines “continuously mentioned” in reports to the NPA, it said.

In one “look-alike, sound-alike” incident, “a series of events occurred before the error was identified”, the NPA said.

“A patient was prescribed nitrofurantoin capsules for the duration of one week, and after consuming a large quantity of alcoholic beverages over a weekend, felt unwell and slept for a few days, relating it to the ‘heavy’ weekend,” the NPA explained.

“After another blood test, the patient’s results showed an abnormal liver function and the GP advised them to reduce alcohol consumption.

“The patient continued to feel unwell, and was absent from work even after finishing the antibiotic course,” the NPA added.

“A friend, who is a GP, questioned the patient and it transpired that metronidazole had been dispensed by the pharmacy instead of nitrofurantoin.”

Flu jab incidents

The NPA also highlighted two errors during the NHS flu vaccination service. In one case, Fluad was administered subcutaneously instead of intramuscularly, and in another a breastfeeding woman received a flu vaccination, despite not being eligible under the patient group direction (PGD).

“Pharmacists must ensure they have fully read and understood what is outlined in the NHS flu PGD and service specification,” Ms Hannbeck stressed.

The majority – 62% – of all incident reports to the NPA continue to involve “no harm” to the patient, while 23% were reported as “near misses”, it pointed out.

Read a full copy of the NPA’s report for July-September 2018 here.

NPA’s tips for avoiding look-alike, sound-alike errors

  • Physically segregate stock
  • Increase staff awareness of importance of errors during training sessions and internal communications
  • Use brightly coloured warning stickers on shelves and/or drawers, or incorporate warning flags into pharmacy computer systems
  • Focus on reducing stress and balancing heavy workloads
  • Implement enhanced checking procedures and avoid self-checking
  • Reconsider how the dispensary is laid out to minimise steps in selecting a product.

Source: Look-alike, sound-alike items, NPA, October 2018

How do you avoid errors during the 'handing out' process in your pharmacy?

Hayley Johnson, Community pharmacist

That metronidazole one is interesting, as IIRC the evidence for a disulfiram reaction with metronidazole is actually shaky at best, though it's been a good few years since I did an evidence review on it. 

Adam Hall, Community pharmacist

The errors mentioned regarding inappropriate flu vaccinations is simply not understanding the PGD.

Adam Hall, Community pharmacist

It's too easy to blame a single factor. Most errors are due to an accumulation - stress,workload, distractions, psychological state of the member of staff etc etc. While I don't necessarily agree with a final check of every item with every patient, making sure of the details of each patient (name, address etc) are some basic checks which will eradicate quick a lot of errors, not least of which is because patients will happily answer "Yes" to any name called.

Meera Sharma, Primary care pharmacist

This is a classic output from an overstretched pharmacy team - somethign that has been highlighted several times in countless articles/documentaries. I agree with some of the comments here, that when I was trained, you always when through the contents of the medicine packet with the patient on collection. However, roll-on a few years, and the pharmacist is lucky if they can mange to get a sip of water while checking at teh rate of a conveyor belt! Couple this with minimum number of staff, less investement in training and loss of experienced staff and this is what results when they give out medicines. I don't blame the staff, I am blaming the culmination of factors that has led to this - despite several pharmacists highlighting these very dangers. Not much changing NPA unless you can persuade your friends at the GPhC/RPS to do something about the root causes! A word used a lot in their documents but not applied to themselves!!

Reeyah H, Community pharmacist

I’m not sure how to balance my workload between me, myself and I. Oh and my tired skeleton staff. Unfortunately these kind of incidents will increase, as the stresses are too high. With regards to checking upon collection, doesn’t work if 90% are delivered. 

Benie I, Locum pharmacist

Your life and family is more important than pharmacy. Use that as your foundation and you'll see yourself right.

Benie I, Locum pharmacist

Obviously errors in general will rise as workload increases and staff numbers are cut. Add in. The factor of plummeting wages causing disgruntlement you have a perfect storm. Doesn’t seem worth it when you can earn more as a train driver backed by the strongest unions in the land. 

Beta Blocker, Primary care pharmacist

Already looked into being a train driver.... 2 places for every 600 applicants. Thats worse than trying to get into medical school lol

Leon The Apothecary, Student

It does raise the question of our support staff being valued and having that valuation being shown in terms of their wages. 

Angela Channing, Community pharmacist

I think they are. The minimum wage is going up again in April. However, most locums and employed pharmacists will start another tax year with no pay rise. One company has told me they cannot afford to increase pharmacist's pay when they are mandated to increase the minimum wage and also fund a work place pension. And while I certainly do not begrudge the support staff an increase, if this carries on every year, then you do start to feel resentful of the increasing work load, with no reward, as pointed out by a commentator above. 

Benie I, Locum pharmacist

That doesn't mean they are valued. |It means they are complying with the law by paying the minimum wage which is quite different. It is all done grudgingly and obviously cheaper than having a run in with law. Bear in mind for similar or more money you can work in JD sports and have a relatively fun time with your mates compared to the constant pressure of being on a pharmacy counter. This is pbeing played out in the difficulty in recruiting pharmacy support staff and the ridiculous high rates of staff turnover.

In summation errors will increase and likely get more serious. the only losers are pharmacists and their staff. Employers especially multiples are laughing all the way to the bank. Remember cuts are being made such that profits of yesteryear can be maintained. Workers bear the brunt of cuts but profits are only shared out at the top.

Chris Locum, Locum pharmacist

I agree. Staff retention is faltering because they can earn elsewhere for a lot less stress. A new member of staff can only do their best, but they are not much use to a pharmacy when others phone in sick or quit. They will follow the pattern soon enough. I don't blame them. Community pharmacy never had a proper career structure, and this is the inevitable consequence. Add in rising costs, decreasing payment with skyrocketing work volume, and you have accelerating risk to a pharmacist's employment livelihood. The RP regulations protect big business - not the public.

Jenny Etches, Community pharmacist

We use a final check system when we hand out. Go through the contents of the bag with the patient before it leaves the shop. We’ve picked up errors on dispensing and labelling but also where the patient has stopped a medicine and it’s still appeared on the Rx (or if they’re on RD/RA and there’s been a discontinuitation since it’s initial inception)  There was an initial resistance by staff because of time limitations but it’s caught quite a few incidents and it’s worth it for that

Interleukin -2, Community pharmacist

Who exactly does this final check ? Thats adding another step or two to an already ridiculously long production process. Robots can do it better it has been proven. Its not realistic to start opening every bag heading out on the counter. I suspect the information commisioner might have a thing or two to say about this practice . I see a vision of one your bright eyed counter assistants gleefully announcing to the inspector that every bag is stripped on the counter and doublechecked..and patient given a chance to identify all their items including suppositories and other items of such ilk....

Leon The Apothecary, Student

I feel that somewhat shows the need for more training with regards for how RA/RD batches should be handled. Like, whenever you see more than one series for a single patient, that's not set up correctly, for example.

Lucky Ex-Locum, Superintendent Pharmacist

That's only feasible up to a certain point though. We do 14000+ a month and there's no way you could do a final check on that many.

Leon The Apothecary, Student

You can do at least a quick one methinks. I've seen it being done in a 20,000 item store, but I think that also highlights the importance of having a good number of people in a team.

A B, Community pharmacist

There is probably a GDPR clause being broken by going through the contents of someone’s medicine bag with them at the counter. Unless you took them to the consultation room I can’t see a way you can do this without breaking confidentiality. 

Benie I, Locum pharmacist

Spot on. An unnamed multiple will then have the pharmacist in front of a panel charged with breaking patient confidentiality. I think you know how it will end.....

Farmer Cyst, Community pharmacist

Someone will be along in a minute to pretend they take the patient to the consultation room each time.

Lucky Ex-Locum, Superintendent Pharmacist

Hmmmm.....could this be because handing out errors aren't the fault of the recording pharmacist?

Uma Patel, Community pharmacist

Agree. Is it selective reporting? Reseach shows an error rate of approx 3% in pharmacies ie approx 30 million errors a year!

How many are reported?



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