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‘Marked decrease’ in patient safety incidents reported during COVID-19

NPA: Reduction may be linked to an “increased workload and pressures due to COVID-19”
NPA: Reduction may be linked to an “increased workload and pressures due to COVID-19”

There has been a “marked decrease” in the number of patient safety incidents flagged to the National Pharmacy Association (NPA) during the pandemic, the organisation has said.

The NPA registered a 14% decrease in the number of incidents reported during the first quarter of 2020, compared to the same time last year, it said in its latest medication safety officer (MSO) report, published earlier this week (June 29).

This “significant reduction” might be linked to an “increased workload and pressures on pharmacy teams due to COVID-19”, which could have resulted in them not “prioritising reporting of patient safety incidents”, the NPA said.

The drop has continued after the first quarter of the year, the report revealed, highlighting “a marked decrease in the number of patient safety incidents being reported” since March. Reports of patient safety incidents did, however, increase by around 3% during the first quarter of 2020 when compared to October-December last year.

C+D has asked the NPA for more information on the decrease in patient safety incidents being reported after March.

Type of errors

Dispensing errors accounted for 81% of incidents reported in the first quarter of 2020, a five percentage point decrease on the previous quarter’s figure.

“Wrong drug/medicine” (26%), “wrong strength” (22%) and “wrong formulation” (12%) incidents were the main categories of errors reported. In total, they constituted 60% of errors reported – a 6% decrease on the previous quarter.

These categories were followed by mismatching patients or mismatching between patient and medicine, which accounted for a total of 15% of errors reported, a 6% increase from the last quarter of 2019.

Overall, 92% of patient safety incidents originated from pharmacy, while 4% came from prescribers.

Delivery errors

Delivery and or collection errors accounted for 7% of the incidents reported, according to the MSO report. The report offered a series of examples to help pharmacy teams reduce these types of incidents.

The NPA said such learnings were “of particular importance due to the increase in demand [for deliveries] under the current unprecedented climate”.

NHS England launched the community pharmacy pandemic delivery service on April 9, as part of which – when no volunteers are available to deliver the medication – pharmacies will be able to claim £5 per delivery, plus an allowance for VAT.

It was recently confirmed that the service will run until July 31.

Contributing factors

“Work and environment factors” (35%) were the main contributing factor to patient safety incidents during the quarter, the NPA said.

“This category includes time pressures, understaffing and poorly organised working environments,” it added.

This factor was followed by look-alike sound-alike errors (22%). The majority of these (8%) involved amlodipine and amitriptyline.

3 Comments
Question: 
What do you make of these findings?

Leon The Apothecary, Student

Without context and reasoning why the number of PSI are down, the statistic is not very useful. 

Not-So-Lucky Ex-Locum, Superintendent Pharmacist

I should think it's because most people are just too damned busy, stressed out and basically had enough to bother with a twinky little report to the NPA. It's a right faff at the best of times. What learning could be had from it anyway? 'Don't have a pandemic' is about all.

Leon The Apothecary, Student

Certainly, and I feel, from my experience anyway, that the issues are the same ones pre-COVID, it's just exacerbated in this climate.

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