NPA medication safety update (MSO report) Quarter 3 and 4 2021 (England)

12th April 2022

Pharmacies have had to adjust to new ways of working due to the COVID-19 pandemic. However, patient safety incidents may occur in the course of your practice. You are strongly advised to please continue to manage and report all patient safety incidents in line with your pharmacy process. This includes completing the recording of the incident details fully.

See our Medication Safety updates with our analysis of patient safety incidents reported during the third (Q3) and fourth quarter (Q4) of 2021 here.

 

In the NPA Q3 2021 medication safety update:

  • Analysis of patient safety incidents reported during Q3 2021
  • Look-alike sound-alike (LASA) errors analysis
  • Original Pack Dispensing and supply of medicines containing sodium valproate open consultation
  • Elvanse capsules vs Elvanse Adult capsules
  • Pharmacy Quality Scheme (PQS) 2021/22
  • Valproate reminder
  • The professional duty of Candour

 

Summary of key findings from analysis of patient safety incidents reported during Q3 2021

  • Overall, there was a 5% increase in the number of incidents reported during Q3 2021, compared to Q2 2021.
  • 95% of incidents reported originated from the pharmacy
  • 3% of errors reported were prescribing errors – this remained the same compared to those reported during Q2 2021
  • The most common type of incident reported during Q3 was ‘dispensing error’, which accounted for 89% of all reported incidents
  • Delivery/collection errors accounted for 7% of the incidents reported; which is a 2% decrease compared to Q2 2021
  • The main categories of errors reported were those involving medication errors such as wrong drug/medicine, strength or formulation, these accounted for 69% of errors reported – this is a 1% decrease from Q2 2021
  • The degree of harm caused to patients reported as ‘none’ (61%) and ‘near miss’ (23%) continues to make up the majority of the reports.
  • There was a 3% decrease in the incidents involving self-checking compared to Q2 2021. This accounted for 6% of errors reported
  • The main contributing factor continues to be ‘work and environment factors’ (43%) and LASA (17%).
  • LASA errors — 2% of all reported LASA errors involved gabapentin and pregabalin

See the MSO Report for Quarter 3 2021, Download Here

 

In the NPA Q4 2021 medication safety update:

  • Analysis of patient safety incidents reported during Q4 2021
  • Look-alike sound-alike (LASA) errors analysis
  • Dispensing prescriptions for children
  • Use of chloramphenicol eye drops in children under two years of age
  • Influenza
  • Pharmacy Quality Scheme (PQS) 2021/22

Summary of key findings from analysis of patient safety incidents reported during Q4 2021

  • Overall, there was a 15% decrease in the number of incidents reported during Q4 2021, compared to Q3 2021.
  • 95% of incidents reported originated from the pharmacy
  • 1% of errors reported were prescribing errors – this is a 2% decrease compared to those reported during Q3 2021
  • The most common type of incident reported during Q4 was ‘dispensing error’, which accounted for 84% of all reported incidents
  • Delivery/collection errors accounted for 9% of the incidents reported; which is a 2% decrease compared to Q3 2021
  • The main categories of errors reported were those involving medication errors such as wrong drug/medicine, strength or formulation, these accounted for 68% of errors reported – this is a 1% decrease from Q3 2021
  • The degree of harm caused to patients reported as ‘none’ (54%) and ‘near miss’ (31%) continues to make up the majority of the reports
  • There was a 1% increase in the incidents involving self-checking compared to Q3 2021.This accounted for 7% of errors reported
  • The main contributing factor continues to be ‘work and environment factors’ (49%) and LASA (18%).
  • 4% of all reported LASA errors involved gabapentin and pregabalin

See the MSO Report for Quarter 4 2021, Download Here

Learn from patient safety events (LFPSE) service

A new national NHS Learn from patient safety events (LFPSE) service, previously called the patient safety incident management system (PSIMS), has been launched and has replaced the National Reporting and Learning System (NRLS) and Strategic Executive Information System (StEIS). Pharmacy contractors can report to the new LFPSE online recording service here.

Contact the NPA Medication Safety Officer (MSO)
NPA members

Independent community pharmacies in England, who are NPA members, can contact the NPA MSO through the Pharmacy Services Team at the NPA for further information, advice and/or support on any patient safety or pharmacy topic/matter by:

Non-members

Independent community pharmacies in England with fewer than 50 branches who are currently not members of the NPA can contact the MSO by email at pharmacyservices@npa.co.uk.

  • Include your pharmacy name, ODS code, name of the owner/superintendent pharmacist and their telephone/mobile number, pharmacy’s NHSmail email address.
  • State ‘Non-member MSO query’ in the subject field.

 

NPA patient safety resources

The full range of the NPA patient safety resources can be accessed on the NPA website: https://www.npa.co.uk/services-and-support/patientsafety

For further information please contact the NPA Pharmacy Services team on 01727 891800 or email at: pharmacyservices@npa.co.uk.

Kind regards,

Jasmine

 

Jasmine Shah

Head of Advice and Support Services

Medication Safety Officer

National Pharmacy Association