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Supervised methadone an 'emerging theme' in dispensing error reports

NPA: More than one case of a double methadone dose given to the wrong patient

The “supervised consumption of buprenorphine and methadone” was an “emerging theme” in patient safety incidents reported in the three months to December.

These included “a patient [being] given another patient’s supervised dose” and “patients [receiving a] standard methadone oral solution” instead of the sugar-free version, the National Pharmacy Association (NPA) said in its latest medication safety officer report.

“In more than one example, more than double the prescribed methadone dose was provided to the wrong patient,” the NPA said in its report, published last week (January 29).

NPA chief pharmacist Leyla Hannbeck told C+D “it is not just methadone [but] controlled drugs in general” that “pharmacists and GPs” are sometimes confused by.

“People feel nervous about them,” she added.

Ms Hannbeck highlighted patient safety incidents linked to the dispensing of opioid medicines as a “recurring and prominent issue”, in her letter to pharmacy superintendents sent with the latest report.

“Increase in serious cases”

“Errors occurring during the dispensing of controlled drugs are very common,” with “incorrect formulations of morphine and tramadol” a “recurring theme”, the NPA said in the report.

While dispensing errors involving “look-alike, sound-alike” medicines are “commonly” reported to the NPA, there was “an increase in serious cases” between October and December 2017.

In one incident, “the dispensing of escitalopram instead of esomeprazole led to the hospitalisation of a patient with hyponatraemia”, according to the NPA.

Confusion between rabeprazole and rivaroxaban, and between rosuvastatin and rivaroxaban, was also highlighted by the NPA in its report.

Dispensing errors involving monitored dosage systems made up 11% of all errors reported in the three months to December.

The “incorrect reconstitution of oral liquids” also led to “serious patient safety incidents” during this period, the NPA said. “In some examples, it is suspected that the incorrect volume of water was used to reconstitute oral antibiotics, which may have led to incorrect dosing and even potential overdose.”

"Small weapon" used

In the same period, a “rare” incident was reported to the NPA where a person brandishing a “small weapon” threatened pharmacy staff in the pursuit of diazepam and pregabalin.

“Pharmacists should be trained in how to respond to such an event, for example, by cooperating with the individual and informing the police as soon as possible,” the NPA concluded.

Last year, C+D exclusively revealed the extent and severity of crime pharmacists and pharmacy staff are facing across the UK.

“Increase in reports”

The overall number of error reports increased by over 45% between 2016 and 2017, with a “significant increase” in the number of reports submitted in the three months to December “compared to previous quarters”, the NPA said.

Ms Hannbeck told C+D that the number of reports the NPA receives “is growing…not because pharmacists are making more errors”, but because “pharmacists are more aware of the importance of reporting and sharing learning”, she stressed.

“What I don’t want to happen is there to be a focus on the numbers, rather than the idea of sharing and improving practice,” she added.

The majority – 64% – of incident reports to the NPA continue to involve “no harm” to the patient, while 22% were reported as “near misses”, the NPA pointed out in its report.

Read a full copy of the NPA’s report for October-December 2017 here.

Are you "nervous" about dispensing certain controlled drugs?

IAN FRASER, Locum pharmacist

Mostly self checking due to understaffing due to cost cuts due to NHS cuts is the answer

The funding model runs so tight they hould just inform the public that getting the wrong meds is just part of the NHS under the current funding model and accept it or go private.

Play safe have an MUR and dont takeany meds home that way everyone wins


Arvind Sami, Locum pharmacist

I think there needs to be some standardisation with the installment scripts, some have a very handy table, others are just wordy paragraphs that contradict itself!

Adam Hall, Community pharmacist

Dispensing CD's has always made me a little nervous, such that I take my time and double check myself before anyone else gets a look at it. The potential for disaster - for the patient as well as the pharmacist - has always instilled this in me. You have to focus on the task in hand - everything else is just white noise. Yes, the pharmacy may have a queue out the door but is that really and excuse for not doing your job properly?

Ilove Pharmacy, Non Pharmacist Branch Manager

I suggest you stay away from a certain high st multiple.

Mohammed Patel, Community pharmacist

A lapse in concentration of only a few seconds can cause a pharmacist to inadvertently destroy what they previously considered to be their "career".

But when they take a step back, take some time for introspection, they will see that it was not a real career and they could have earned more money by managing a McDonalds.

Ilove Pharmacy, Non Pharmacist Branch Manager

AN infinitely better career choice in these modern times.

Mohammed Patel, Community pharmacist

If the error rate is increasing, then as I see it there are two avenues you can take.

You can either come down hard on the pharmacists who are making these errors in the hope that the "stick" method will prevent them from doing it again in the future. This costs money, causes stress and can make pharmacists unwell or feel that they need a new career. It make people regret choosing their profession, make their contribution feel unwanted and ultimately propagate further feelings of negativity toward the industry. This method is what we seem to be seeing today.

Or you can be a bit more sensible, and try to ask why these error rates are increasing. We all know why error rates are increasing, but as individual pharmacists we can do little about it. When the BBC is doing more than the GPhC, intelligent people should be asking why that is.

When a patient is harmed by an error, it is obviously much, much easier to destroy the career of the unfortunate individual pharmacist involved, than it is to quiz a large multinational conglomerate on their working practices. Because almost all the bosses of the companies in question are not registered pharmacists.

Disillusioned Sussex chic, Dispenser Manager/ Dispensing Assistant

I do agree with this statement however, i have worked in pharmacies where pharmacists 'do love to chat' and I now of the same mistake going out three months in a row by the same dispenser (who wasn't HCA trained) and the same pharmacist who worked there regularly as a locum. I believe that a little more time taken in the first place would save this type of mistake happening but, as was rightly said above, the 'big bosses' who are not trained want blood out of a stone to meet 'targets'. Bring back the old days when an area/regional manager is actually trained and has worked their way up the ladder from the shop floor, NOT 'good with numbers and comes from whatever - 4 - you.

Manufacturers also have a responsibilty to ensure that there is no confusion in the colour of boxes for different strengths of the same drug. We know this is done because it's cheap and they just want money but, they should be taken to task too. the Buyers should also take a responsibily to ensure when drugs are sent out to pharmacies, these things should be pointed out in a BIG WARNING, catches attention doesn't it? well why are they not doing it?.

Mohammed Patel, Community pharmacist

Because that would be common sense, and we are talking about the UK pharmacy industry here. 

Valentine Trodd, Community pharmacist

"patients [receiving a] standard methadone oral solution” instead of the sugar-free version..."

Ohh, what you gonna do, call the polis?

In the name of God, what possible harm could this cause?! I think now and then we need to stop, take stock and stop worrying about bloody nonsense like this.

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...

Honest Tikes, Sales

The NPA it must be remembered is heading the way of the dinosaurs.The diminishing independent base that funds it is treated to a relationship not that much different from that between a multiple and its branches.In their advice they pass on the missives from on high that must be obeyed to the letter.Once upon a time their advice would offer practical solutions to aid compliance,now it is necessary to follow to the letter all directives lest any responibility fall upon the NPA aparatchik .How many of them have owned their own pharmacy?How many were trained by Boots?

Owen Davies, Locum pharmacist

Tooth decay.

Owen Davies, Locum pharmacist

Tooth decay.

Valentine Trodd, Community pharmacist

I think that myth has been busted a long time ago...

Owen Davies, Locum pharmacist

But what if that one-off incorrect dispensing of standard sugary methadone was the gateway to harder substances? It could be a slippery slope to a life of fizzy pop, bonfire toffees and candy floss...

Valentine Trodd, Community pharmacist

Next thing they'll be on the Coke (a-cola)!

Mohammed Patel, Community pharmacist

A sensible and intelligent point of view. I suspect that you are in the wrong profession, because in community pharmacy it is a heinous crime and you will be locked up forever.

Steven Marley, Community pharmacist

Take care of the small stuff, the big stuff takes care of itself.....

Although you make a valid point

Jonny Johal, Pharmacy Area manager/ Operations Manager

I think the real problem is that the statistics are totally inaccurate due to under-reporting. After almost 40 years since qualifying, I still come across pharmacists who claim they have never made any mistakes.

Valentine Trodd, Community pharmacist

I agree. I suspect that under-reporting is so rife that they are embarrassed to release the actual figures.

Ilove Pharmacy, Non Pharmacist Branch Manager

With regards cooperating when threatened with a weapon, I can imagine a certain multiple could view it as being an inside job. And Off to Canary Wharf to the have the ‘striking off’ rubber stamped.

Reeyah H, Community pharmacist

Bit strange, talking about supervised errors and then a small weapon being brandished?! Is this an error in reporting?!  

Andy Burrells, Community pharmacist

I wonder how many came from self checking?

Daniel McNulty, Superintendent Pharmacist

“Errors occurring during the dispensing of controlled drugs are very common,” 


Can the NPA define very common in terms of errors per dispensing?

Jonny Johal, Pharmacy Area manager/ Operations Manager

 I too have seen increasing numbers of CD errors by other pharmacists in recent years. I don’t think there is more stress in my work place, but rather inexperienced pharmacists who thinks they know everything, laziness, and in some cases unfamiliarity with regulations.

I can give examples of all of the above. 

Paul Samuels, Community pharmacist

A valid point about a few inexperienced pharmacists who think they know it all.Have in the past pulled up a few who thought they knew it all & never made any errors!!--bad attitude & sheer conceit.


That said 


Disillusioned Sussex chic, Dispenser Manager/ Dispensing Assistant

two questions to the area manager posting. have you worked in the pharmacy situation ie dispensary yourself and are you pharmacist trained? anyone can look at a book and make graphs and write reports but, not everyone can understand WHY these mistakes are happening in the first place. It's only then that the real problem can be tackled and improved.

Jonny Johal, Pharmacy Area manager/ Operations Manager

Yes, qualified since 1979. As for errors, I have been involved with those at every stage of my career, I do not subscribe to the simple assumption that stress = errors, I have known pharmacists who thrive on stress. 

Jonny Johal, Pharmacy Area manager/ Operations Manager

Also, in the vast majority of dispensing error reports I saw, the boxes “busier than normal” and “less staff than usual” were ticked. In one case I investigated, those boxes were ticked when the PMR showed there were only 6 items dispensed in that hour, with long down time before and after the error, 3 OTC transactions on the chemist counter. The staffs clock-in records didn't show any absentees either. Mistakes can happen during quiet periods too, I learnt not to rely too much on the error reports filed by pharmacists.


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