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'Spike' in claims over escitalopram and esomeprazole confusion

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Leyla Hannbeck: Controlled drugs continue to be one area pharmacists "still a bit unsure of"
Leyla Hannbeck: Controlled drugs continue to be one area pharmacists "still a bit unsure of"

The National Pharmacy Association (NPA) received “at least six” claims to its insurance department as a result of escitalopram and esomeprazole being confused, C+D has learned.

Antidepressant escitalopram and proton pump inhibitor esomeprazole were the third most commonly confused medicines dispensed in pharmacies in the three months to September, according to the NPA’s latest medication safety officer report, published on October 19.

This specific dispensing error led to “a number of [patient] claims” being reported to the NPA’s insurance team, after patients experienced “symptoms” as a result of the error, the organisation’s chief pharmacist Leyla Hannbeck told C+D.

“Pharmacists need to be careful, because all of a sudden there has been a spike in [claims relating to these two drugs],” Ms Hannbeck warned.

Midazolam and morphine were the most commonly confused “look-alike, sound-alike” medicines between July and September, followed by apixaban and rivaroxaban, according to the NPA report.

Pre-reg errors

“A number of errors” over these three months involved pre-registration pharmacists, according to the NPA.

Both dispensing errors and errors when selling over-the-counter (OTC) products were reported, and the NPA suggested “the main contributory factor” could be “the lack of training and experience available..during the early stages of the pre-reg training year”.

Every placement pharmacy must have relevant standard operating procedures in place for pre-regs to follow, and a pharmacist on-site to mentor them, Ms Hannbeck stressed.

“Are [pre-regs] aware of the protocols when selling OTC products? Are they aware of the questions they should be asking and when to refer [a patient] to a pharmacist?” she asked.

Child hospitalised

“A number of incidents involving children” were also reported, including a child being hospitalised.

The child was prescribed “ciprofloxacin oral suspension 250mg/5ml, at a dose of one 5ml spoonful twice a day, for seven days”, the NPA reported. However, “the product was incorrectly labelled as five 5ml spoonfuls, twice a day”, and led to the patient being hospitalised “due to the increased risk of QT prolongation and seizures associated with ciprofloxacin overdose”, the NPA said.

“The incident was identified [when] the patient’s parent contacted the pharmacy to query why the oral solution was running out so quickly,” it said.

Ms Hannbeck stressed the importance of “additional checks” when it comes to dispensing children’s medicines, and said the NPA would be producing resources on this “in the coming months”.

Flu jab error

Two incidents of vaccination errors were reported in the three months to September, according to the report, whereby patients received either a second meningitis or flu vaccination from a pharmacy, despite having already been vaccinated by a GP.

“Pharmacists should take steps to confirm patients are scheduled to receive a vaccination, to prevent duplication of doses,” the NPA said.

Dispensing opioids

There was also “more evidence of errors related to the dispensing of controlled drugs” and “quite a lot” of reports from members around the dispensing of opioids, between June and September, Ms Hannbeck said.

“Controlled drugs continue to be one area that pharmacists are still a bit unsure of,” she added.

In her letter to all superintendents, Ms Hannbeck said errors in opioid dispensing “has been a recurring issue for many years and associated with many patient safety incidents and numerous deaths”.

She stressed the importance of ensuring the appropriate doses are prescribed, and said the NPA has produced a patient safety resource to help its members tackle the number of errors.

“Focus on learning, not numbers”

While the number of patient safety incidents to the NPA “has remained consistently high”, the “quality” of incident reports submitted is continuing to improve, it said.

“The number of reports has increased [this quarter], but this is because pharmacists know they need to report. [They know] the importance of learning and sharing,” Ms Hannbeck said.

The NPA is “keen not to reveal” the number of reports it receives from pharmacists, “because the focus should be on awareness, learning and sharing”, she added. She stressed that all reports remain anonymous and encouraged pharmacists to keep reporting to the NPA.

The majority – 70% – of incident reports to the NPA continue to involve “no harm” to the patient, the NPA added.

4 Comments
Question: 
Are you surprised by the dispensing errors reported last quarter?

Jonny Johal, Pharmacy Area manager/ Operations Manager

If the NPA is refusing to publish their full set of data and put these incidents in context, I wonder what is the real motive behind this article?

Stephen Gabell, Community pharmacist

I have recently moved from the UK to Canada, and I've spent time in two different pharmacies so far. One was a branch of one of the large multiples, and the other is a small independent. The computer systems in both require that the product being dispensed has it's barcode scanned before a dispensing label is printed. After eleven days, I have yet to see a picking error, and this is due to the way the system is designed. Canadian pharmacies do seem to dispense a smaller volume than UK pharmacies, but some aspects are much more complex, such as dealing with insurance claims and extemp dispensing.

Any system which relies on humans will always be prone to error, and errors will continue to happen in the UK until more technology is involved in the dispensing process.

Ilove Pharmacy, Non Pharmacist Branch Manager

Don't worry about that, technology is coming. It's called Robots and no pharmacists.

Valentine Trodd, Community pharmacist

To the NPA...

I've asked this question before, didn't receive any response, so I'll ask again.

The quarterly report provides some interesting reading (and has some nice graphs). I won't deny that any information regarding dispensing errors that provokes some reflection on our individual practice is helpful. However, one vital statistic is consistently left out in EVERY one of these quarterly reports. In my admittedly limited experience of statistics, I usually expect to  see the SAMPLE SIZE that the analysis is based upon. So... how many dispensing errors were reported to the NPA in the last quarter? Perhaps it's so low as to be an entirely unrepresentative sample of the parent population? In which case the quarterly results would be interesting, but entirely unrepresentative. Personally, I find it a little insulting that the NPA are, as you put it, 'not keen to reveal' the number of reports it receives - without this number, we can't put the other statistics in context. I think as pharmacists, and indeed contributors to this study, we are entitled to know the results? Being kept in the dark doesn't really encourage future cooperation...

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