Top tips for minimising risk of dispensing errors – MSO Quarterly report (January – March 2018)

10 May 2018

Superintendent update on the NPA Medication Safety Officer's Quarterly report - Quarter 1 2018

Dear Superintendent,

I attach my Patient safety quarterly report Quarter 1 (January – March) 2018  which includes a summary of the most common dispensing errors reported to the NPA during the quarter, along with top tips for minimising patient safety incidents.

Errors involving delivery drivers
Dispensing errors involving delivery drivers made up 5 per cent of incidents reported during Quarter 1 of 2018. The most common errors involving deliver drivers included:

  • Medication delivered to the wrong patient due to similar looking and/or similar sounding names
    • One incident led to hospitalisation of a patient
  • Medication delivered to the wrong address – due to incorrect address on the bag label and/or change of patient address but GP, lack of pharmacy awareness of this
  • Standard Operating Procedures (SOPs) for delivery drivers not followed, or incorrectly followed

Another incident occurred whereby a temporary delivery driver posted medicines through the letterbox of a patient not at home. The delivery driver had not read the pharmacy SOPs and nor gained consent from the patient. Please see our MSO report for further information.

The NPA has produced a SOP on delivering pharmacy items, with a focus on patient safety. In addition, there is a separate SOP on the delivery of Schedules 2 and 3 Controlled Drugs (CDs).

Errors involving CDs
Dispensing errors involving methadone were also reported (4 per cent) during Quarter 1 2018. Examples of a number of cases reported include:

  • Patients receiving standard methadone oral solution instead of sugar free
  • Incorrect dose/quantity dispensed to the patient and supervised
  • Confusion around the appropriate date, Home Office wording and supplies around the Bank Holidays

In one example, an empty bottle of methadone was found in another patient’s bag, raising patient safety concerns.

In addition, there were many incidents reported as wrong formulation involved the following CDs in Quarter 1 2018, for example:

  • Buprenorphine: tablet – oral lyophilisate
  • Morphine: tablet – capsule
  • Tramadol: capsule – modified release capsule

Errors involved in Repeat Management Service
There were several incidents (3 per cent) reported whereby pharmacy contractors are requesting prescriptions on behalf of patients but the surgery did not process the prescriptions, leaving the patient without medication for several days. In one particular incident, the pharmacy could not give an emergency supply of the medication as it was a Controlled Drug (CD) — buprenorphine patches (a Schedule 3 CD), leaving the patient in pain and discomfort.

Pharmacy contractors are reminded to ensure robust systems are in place to ensure the Repeat Management Service is running efficiently. The NPA has produced the ‘Repeat prescription management service: guidance’, to support pharmacy teams implementing and managing a Repeat Management Service.

NPA support
The NPA has published a suite of patient safety SOPs to assist you in ensuring you have robust processes in your pharmacy for dispensing high risk medicines such as oral methotrexate and paraffin-based products. These and other patient safety resources can be freely accessed from our patient safety page on the NPA website.

Quality payments scheme
The Pharmaceutical Services Negotiating Committee (PSNC) has announced the extension of the quality payment scheme for the first six months of 2018/19; the next review point will be on 29 June 2018. The patient safety report remains one of the eight quality criteria. If this criterion was claimed in 2017, the same results cannot be reported and therefore, the previous report will need to be reviewed and updated to demonstrate how the quality criterion has been met.

The NPA has produced general guidance, monthly and annual template report forms to help meet this patient safety quality criterion, available on the NPA website.

This quarterly report includes an analysis of all reported incidents and learnings shared from community pharmacies; this can be used to meet the national sharing component of the annual patient safety report criterion for the quality payments scheme.

For further information on any of the above, please contact the NPA Pharmacy Services team on 01727 891 800 or email .

Kind regards,

Leyla Hannbeck MSc, MRPharmS, MBA
Chief Pharmacist