Medicines Safety Officer (MSO) update Quarter 2 2019
Superintendent update on the MSO Quarterly report (April-June 2019)
I am pleased to publish my Medication Safety Officer’s (MSO) report for Quarter 2 (Q2) of 2019, please click here to download https://www.npa.co.uk/wp-content/uploads/2019/07/MSO-report-Q2-of-2019.pdf. In this report, I have included important patient safety updates, and an analysis/summary of the most common patient safety incidents reported to us during the quarter.
There was a 19% decrease in the total number of patient safety incidents reported in Q2 of 2019 compared to Quarter 1 (Q1) of 2019. The review point for the Quality Payments Scheme was in February 2019 and there were a particularly high number of reports received during this month. This may have contributed to the decrease in reporting seen between the quarters.
Summary of MSO report analysis for Quarter 2 of 2019
Origin of patient safety incidents
Of the incidents reported during Q2, 95% occurred in the pharmacy. Only 2% of errors reported were prescribing errors – this is a 3% decrease from Q1. One example where a pharmacist’s clinical check identified a prescribing error and prevented patient harm involved a pharmacist querying the suitability of topical clobetasol prescribed for a young child. This is considered to be a very potent steroid. It transpired that it was prescribed as an alternative to clobetasone cream (a steroid of moderate potency) which was out of stock at that time. After the incident was highlighted to the prescriber, a new prescription was issued for a more appropriate item. I would like to remind pharmacists and their teams that is important to report prescribing errors because increased reporting allows identification of trends and increases learning.
Medication error categories and incidents reported during Q2 of 2019
- The main categories of error reported were those involving medication errors such as wrong strength (27%), drug (27%) or formulation (13%).
- There has been a notable number of ‘wrong drug’ incidents reported during this quarter involving Direct Oral Anticoagulants (DOACs) (5.6%). Rosuvastatin and rivaroxaban being dispensed in place of each other was the most common type of ‘wrong drug’ error reported.
- Mismatching between a patient and medicine or mismatching patients accounted for 8.5% of the errors reported.
Degree of harm caused to patients by incidents reported during Q2 of 2019
The degree of harm caused to patients reported as ‘none’ (56%) and ‘near miss’ (29%) continue to make up the majority of report. There were no incidents reported during Q2 which resulted in death.
There was a 4% decrease in the number of errors reported which involved a pharmacist self-checking compared with Q1 of 2019; 11% of incidents reported during Q2 involved a pharmacist self-checking. I have provided advice in the full report to help prevent self-checking errors in situations where self checking is unavoidable.
In addition to analysis of LASA errors, this MSO report also aims to provide clarity on the types of errors that should be reported as LASA errors. On analysis of all of the reports submitted as LASA errors this quarter it was apparent that 32% of these errors were wrong strength, wrong formulation or errors involving similar packaging and not LASA errors. There is a lot to learn from LASA errors and unclear data can prevent learning. To aid accurate reporting of these incidents going forward, the full MSO report provides a guide to what a LASA error is.
The full MSO report discusses the following common types of error and advice to prevent them from occurring.
- Dispensing methadone.
- Patients taking long-term corticosteroids.
- Medicines omitted from a monitored dosage system (MDS).
Medicines & Healthcare products Regulatory Agency (MHRA) updates
I would like to remind you of some key MHRA updates issued in Quarter 2 of 2019:
- Oral retinoid medicines: revised and simplified pregnancy prevention educational materials for healthcare professionals and women
- Videos to support patients in completing a yellow card report have been produced
- Valproate medicines and serious harms in pregnancy: new Annual Risk Acknowledgement Form and clinical guidance from professional bodies to support compliance with the Pregnancy Prevention Programme
Reporting errors through the NPA incident reporting platform (IRP)
One of the benefits of reporting incidents through the NPA IRP is that the incident report receipt is sent via email, helping to reduce administrative time as this can be retained for pharmacy record keeping purposes. I would like to make you aware that currently there are multiple receipts not reaching the pharmacies who have submitted the report as incorrect email addresses have been provided; before submitting the report, please check to ensure that the email address included is correct.
For further information, advice and/or support on any patient safety or pharmacy topic/mater, please contact the NPA Pharmacy Services team on 01727 891800 or email at firstname.lastname@example.org.
|Leyla Hannbeck MSc, MRPharmS, MBA
NPA Director of Pharmacy
Medication Safety Officer