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Pharmacy staff shortages contributing to patient safety incidents

NPA: A lack of staff is forcing pharmacists to self-check
NPA: A lack of staff is forcing pharmacists to self-check

Staff shortages and time pressures are being reflected in the number of patient safety incidents reported in pharmacies, the National Pharmacy Association (NPA) has said.

The number of reports citing “work and environment factors” as the main contributor rose by 2% in the three months to December – compared with July-September – accounting for 47% of all patient safety incidents, the NPA revealed in its latest medication safety officer (MSO) report last month (January 31).

The NPA attributed the rise to “workload, distractions and time pressures due to staff shortages and the pharmacist trying to undertake all tasks themselves and not delegating to other pharmacy staff where appropriate”.

NPA director of pharmacy Leyla Hannbeck said 21% of the patient safety incidents citing “work and environment factors” were due to staff shortages.

The lack of staff meant the pharmacist was forced to carry out the dispensing process themselves, and of the reports submitted in the three months to December, 21% involved a pharmacist self-checking, including the clinical and accuracy check, the NPA added.

Nearly a quarter (22%) of these self-checking incidents involved the wrong strength of medicine being dispensed.

“Without specific guidance on self-checking from the General Pharmaceutical Council, only do so as a last resort,” Ms Hannbeck advised.

Look-alike, sound-alike errors

The two most common errors reported were “wrong drug/medicine”, accounting for 29% of all patient safety incidents, and dispensing the wrong strength, accounting for 25%.

For the October-December report, superintendents could for the first time select “look-alike, sound-alike factors” as a contributor to incidents where the wrong drug was dispensed, to coincide with the new quality payment criteria on patient safety reporting.

Similar looking and/or sounding medicines contributed to 22% of patient safety incidents, with the most commonly mistaken medicines being amlodipine and amitriptyline, and gabapentin and pregabalin, the NPA said.

In “a rare, but serious” look-alike, sound-alike incident, a child received olanzapine orodispersible tablets instead of omeprazole dispersible tablets. “The patient was admitted to hospital after displaying signs of drowsiness following ingestion of three tablets,” the NPA noted.

Short-dated stock

In one incident Ms Hannbeck highlighted, a pharmacy received a handwritten hospital prescription for four bottles of Travatan eye drops to be administered over a four-week treatment period. At the time of dispensing, the short-dated eye drops were in-date; however, two bottles expired halfway through the treatment.

“When the pharmacist re-ordered the bottles to rectify the error, they received another set of very short-dated stock,” Ms Hannbeck explained.

“Always check when dispensing short-dated stock and ensure it will not expire before the end of the treatment period,” and “always ensure date checking is completed…at least every three months”, the NPA advised.

Where did the errors originate?

The majority of all incident reports – 58% – continue to involve no harm to the patient, while 30% were reported as “near misses”. In the remaining incidents of “low” (10%) and “moderate” (3%) degree of harm, patients experienced side effects, but not permanent harm, the NPA said.

While 96% of incidents originated from the pharmacy, 3% were due to prescribing errors, “most of which were following patient discharge from hospitals”, it said.

An error by both a prescriber and a pharmacist resulted in “severe harm” being caused to one patient.

“A patient with a severe allergy to penicillin was prescribed and dispensed Augmentin tablets 625mg (co-amoxiclav) for a chest infection. Although the allergy was recorded on the patient's medication record, it was unusual that no individual highlighted this,” the NPA said.

“The patient took four tablets and started to develop a skin rash. The error was picked up by the pharmacist – as the patient was concerned – and was referred back to the prescriber.

What is C+D doing about pharmacy pressures?

C+D created a briefing document, which was passed to England’s chief pharmaceutical officer Keith Ridge by the Royal Pharmaceutical Society last month to persuade him of the damage stress is causing to community pharmacy. Download the document, and read C+D’s in-depth coverage of the data.

Let C+D know about your own experiences of stress by emailing [email protected]. Please state if you prefer your comments to remain anonymous.

Has your pharmacy struggled with staff shortages?

Soon-To-Be Ex-Pharmacist, Superintendent Pharmacist

The follow-up artice is entitled - 'The Pope is Catholic and bears do dumps in forested areas'. Who knew??

cardiff pharmacist, Superintendent Pharmacist

2006/7 688m items dispensed in England

2016/2017 1,015m items dispensed in England

47% INCREASE...but remuneration DOWN. Minimum Wage UP, qualifications of staff and thus salries UP. DoH had productivity deflator in remuneration. Pharmacy probably has best productivity increase of any industry in UK! BUT there is no more left, we need more remuneration for more staff.

We’re all doomed, Locum pharmacist

That Boots fellow whistle blew and nothing happened I recall. Haven’t done a Locum since 18th December after enduring inadequate staffing and never intend to do so again. A shambolic state of affairs. 36 years and out yippee

Reeyah H, Community pharmacist

To be honest, if the GPhC asked me to get more staff in, I may have to just shut down as I can’t afford any! 

Graham Turner, Non Pharmacist Branch Manager

To be honest, shutting down is probably better than spending the rest of your life feeling terrible because a dispensing error killed someone. There are other jobs out there, not just pharmacy, and a lot of them pay better for office hours only.

Soon-To-Be Ex-Pharmacist, Superintendent Pharmacist

Tell us what the other jobs are!! I want one!!

Anant Bhogaita, Locum pharmacist

Can’t see why the GPhC is not dealing with staffing issues. We are doing too much with less staff. Needless audits and paperwork when dispensing volume is increasing. With the high volume of EPS, we are just professional conveyer belt operators working in a Victorian age! The PDA Charter for Pharmacies should be incorporated into the Indemnity Insurance policies.

Graham Turner, Non Pharmacist Branch Manager

You can't see why they are doing nothing? Just think about it. There are a few obvious answers, many of them have been mentioned on here over the last few years.

Chemical Mistry, Information Technology

Pharmacy is like a monty python sketch !  NSAID audit when there was a Naproxen shortage and now everyone is completing Patient Safety when the main way to increase  patient safety is to have more staff however take for example the Patient Safety group who does that group consist of oh yes People who work for the multiples so things will never change I know if worked for example the chemist and druggist I would challenge these people but then you cannot bite the hand that feeds you i.e. Look at the adverts on the chemist and druggist and see which companies mainly advertise there.

Angry Pharmacist, Locum pharmacist

OH YOU THINK??? I’ve just done 4 shifts already this week you know how many staff I had?? Absolutely ZERO!! Welcome to pharmacy in 2019, understaffed, underpaid and UNDERVALUED! 


Graham Turner, Non Pharmacist Branch Manager

Yes and if you report the situation, you will be told that you have the power to close the pharmacy and not work. And then kiss goodbye to ever working at that pharmacy again, try explaining the situation to your building society when you default on your mortgage.

Benie Locum, Locum pharmacist

Ground breaking stuff I'm reading here. Less staff = Errors. Maybe hand these findings to the multiples pronto. Maybe they'll pay big money for it.

Ebers Papyrus, Pharmaceutical Adviser

It’s easy to criticise the GPhC but they aren’t involved in pharmacy remuneration and cost of service. This is causality related to the pharmacy cuts and was predicted, it’s the law of unintended consequences. Force a change from the current framework of staffing levels and you’ll lose half the network. The pharmacies will simply become unviable.

It is extremely worrying from a patient safety perspective and for those at the coal face the environment has become extremely challenging.

Benie Locum, Locum pharmacist

So patient safety is nothing to do with the GPhC ? Wow ! You should let them know this is not within their remit so they can reduce their fees.

Graham Turner, Non Pharmacist Branch Manager

GPhC use the phrase "we are only mandated to protect the public" to avoid doing anything. Now we have a clear patient safety issue and they are doing nothing about that either. What on Earth ARE they actually doing? Sending out letters once a year to collect their fees?

The only thing that they seem to be doing is coming down on individual pharmacists and according to GPhC regulate, since 25 September last year they have done seven hearings, obviously not including hearings held in private.

With the cost of the GPhC, I would expect them to do 7 in one day! What the hell is going on?

They are haemorrhaging money, but because it's "other people's money" they could not give a rat's backside.

Some of the FtP cases seem to take years, why is this? To harrass and upset the registrant as much as possible?

Ronald Trump, Pharmaceutical Adviser

The GPhC need to set minimum legal staffing hours but do not have the cajones. Also, how about putting more than one pharmacist in the busiest stores to ease the burden on the sole RP? Most of the multiples will not do this because they would rather deliver to their shareholders than protect their patients.

GPhC where are you?

So glad I left community pharmacy! Not worth the stress. 

Graham Turner, Non Pharmacist Branch Manager

I suspect that most UK pharmacists feel that they are too heavily invested in the profession and must stick with it, but why would you stick with such an awful role? The quicker you get out, the quicker you will be happy.

You've still got a degree, there are loads of things you can do.

Leon The Apothecary, Student

Student Finance will fund people into a different healthcare profession for the most part, even if it is a second degree.

Graham Turner, Non Pharmacist Branch Manager

Not enough staff = more pressure = more errors = patient safety compromised.

This is a given. A no-brainer. To perform the same amount of work with fewer staff means that there will be more errors, and more patients could be harmed.

So where is the GPhC, seeing as they only take action to protect the public?

Are they using all their time to come down on pharmacists who are accused of stealing a jumper or a Mars bar? What a joke they have become.

Do the GPhC lack the power to deal with this matter, or are they avoiding it because they are in cahoots with certain multiples?


The issue of UK pharmacies being short staffed has been around for YEARS now, and they have done nothing (except I think Rudkin put out a useless statement admitting that it "might" be an issue, still zero action).

So we have a very expensive regulatory body who are supposed to be protecting the public from harm caused by pharmacies (and/or pharmacists), and they have based themselves in Canary Wharf, London. Yet they are not actually protecting the public but instead furthering their own interests. I think it's high time this issue was brought to the attention of the public, to be honest, it's a disgrace.

I'm sure they will soon come up with an excuse as to why they cannot tackle the issue of pharmacy understaffing, they've got an answer for everything. But anyone with half a brain can hypothesise about the real reasons.

If you are only mandated for one thing, and you aren't even doing that, then I believe that you owe it to your registrants to explain the situation.

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