NPA medication safety update (MSO report) Quarter 4 2020 (England)

09 Apr 2021

During the coronavirus (COVID-19) pandemic, since March 2020, there has been a significant decrease in the number of patient safety incidents being reported.  During this unprecedented time, we appreciate you are currently extremely busy with a massively increased workload. 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.

  • 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 carefully and fully

Medication Safety update presenting our analysis of patient safety incidents reported during the fourth quarter of 2020 (Q4) – access the full update here.

In the NPA Q4 2020 medication safety update:

  • Analysis of patient safety incidents reported during Q4 2020
  • Look alike sound alike (LASA) errors analysis
  • Influenza incidents
  • Oxycodone formulations
  • National Patient Safety Alerts- changes to MHRA drug alert titles and classifications
  • Antiepileptic drugs – review of safety use in pregnancy
  • Yellow Card reporting – including COVID-19
  • Incident reporting SOP/near miss logs and duty of candour
  • Reporting patient safety incidents, including the professional duty of candour
  • Relevant links
  • Contact your MSO

Summary of key findings from analysis of patient safety incidents reported during Q4 2020

  • Overall, there was a 6% increase in the number of incidents reported during Q4 2020, compared to Q3 2020.
  • Compared to the same quarter in 2019, there was a 27% decrease in the number of incidents reported during Q4 of 2020.
  • 96% of incidents reported originated from the pharmacy.
  • 2% of errors reported were prescribing errors.
  • The most common type of incident reported during Q4 was ‘dispensing error’, which accounted for 82% of all reported incidents.
  • Delivery/collection errors accounted for 9% of the incidents reported; an increase of 2% since Q3 2020.
  • The main categories of errors reported were those involving medication errors such as wrong drug/medicine, strength or formulation, these accounted for 66% of errors reported – this is a 3% decrease from Q3 2020.
  • The degree of harm caused to patients reported as ‘none’ (61%) and ‘near miss’ (25%) continues to make up the majority of reports.
  • There was a 5% increase in the incidents involving self checking compared to Q3 2020.
  • The main contributing factor continues to be ‘work and environment factors’ (41%) and LASA (23%).
  • LASA errors — 3% of all reported LASA errors involvedgabapentin and pregabalin.

 

The Professional duty of candour
The General Pharmaceutical Council (GPhC) and the Pharmaceutical Society of Northern Ireland (PSNI) have previously issued a joint statement with other regulators about the professional duty of candour and the importance of being open and honest with patients when something goes wrong with their treatment or care which causes or has the potential to cause harm or distress. Healthcare professionals (including pharmacists and pharmacy technicians) must:

  • Inform the patient (or, where appropriate, the patient’s carer/representative) when something has gone wrong
  • Apologise to the patient (or, where appropriate, the patient’s carer/representative)
  • Rectify the error or offer an appropriate remedy/ support to put matters right (if possible)
  • Explain fully to the patient (or, where appropriate, the patient’s carer/representative) the short and long term effects of what has happened

The joint statement also states: “Healthcare professionals must also be open and honest with their colleagues, employers and relevant organisations, and take part in reviews and investigations when requested. Health and care professionals must also be open and honest with their regulators, raising concerns where appropriate. They must support and encourage each other to be open and honest and not stop someone from raising concerns.”
REF: https://www.pharmacyregulation.org/news/professional-duty-of-candour-joint-health-regulators-statement

 

NPA resources

Incident reporting SOP and near miss logs
A patient safety incident is where an unintended/unexpected event occurs in which harm may or may not have been experienced by one or more customer/patient/pharmacy staff. Patient safety incidents may occur in the course of your practice. It is important to manage and report all patient safety incidents in line with your usual pharmacy process and requirements in your relevant UK country. This includes completing the recording of the incident details carefully and fully. It is vital to ensure the whole pharmacy team are aware of the pharmacies processes with dealing with incidents.

To support you, we have updated some patient safety resources on incident reporting:

We would also like to remind you of other resources, which may support reporting:

 For further information refer to NPA Patient safety incidents, including professional duty of candour page

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.