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

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

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.…

NPA medication safety update (MSO report) Quarter 2 2021 (England)

  Medication Safety update presenting our analysis of patient safety incidents reported during the second quarter of 2021 (Q2) – access the full report here In the NPA Q2 2021 medication safety update: Analysis of patient safety incidents reported during Q2 2021 Look alike sound alike (LASA) errors – analysis New prescribing advice issued for patients requiring a specific levothyroxine product Fexofenadine reclassification Elimination of bottles of liquefied phenol 80% Valproate reminder Root Cause Analysis- template Learn from patient safety events (LFPSE) service Yellow Card reporting – including COVID-19 Reporting patient safety incidents and professional duty of candour Relevant links Contact your MSO   Summary of key findings from analysis of patient safety incidents reported during Q2 2021 Overall, there was a 2% decrease in the number of incidents reported during Q2 2021, compared to Q1 2021. 93% of incidents reported originated from the pharmacy 3% of errors reported were prescribing errors – this remains the same as the number of incidents reported during Q1 2021 The most common type of incident reported during Q2 was ‘dispensing error’, which accounted for 84% of all reported incidents. Delivery/collection errors accounted for 9% of the incidents reported; this is the same as Q1 2021.…

NPA medication safety update (MSO report) Quarter 1 2021 (England)

  Medication Safety update presenting our analysis of patient safety incidents reported during the first quarter of 2021 (Q1) – access the full report here In the NPA Q1 2021 medication safety update: Analysis of patient safety incidents reported during Q1 2021 Look alike sound alike (LASA) errors analysis Use of chloramphenicol eye drops in children under two years of age Lithium- new SOP and guidance for monitoring during COVID-19 Incident reporting- new SOP and near miss log including the professional duty of Candour Medicines in pregnancy- valproate registry Dispensing prescriptions for children Learn from patient safety events (LFPSE) Service COVID-19: Yellow Card reporting including COVID-19 vaccines Reporting patient safety incidents and professional duty of candour Relevant links & signposting Contact your MSO   Summary of key findings from analysis of patient safety incidents reported during Q1 2021 Overall, there was a 6% decrease in the number of incidents reported during Q1 2021, compared to Q4 2020. 95% of incidents reported originated from the pharmacy 3% of errors reported were prescribing errors – this is an increase of 1% compared to the number of incidents reported during Q4 2020 The most common type of incident reported during Q1 was ‘dispensing error’, which accounted for 85% of all reported incidents.…

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

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.…

NPA medication safety update (MSO report) Quarter 3 2020 (England)

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 third quarter of 2020 (Q3) – access the full update here. In the NPA Q3 2020 medication safety update: Analysis of patient safety incidents reported during Q3 2020 Look alike sound alike (LASA) errors analysis, including trends in gabapentin and pregabalin errors Controlled Drug incidents and COVID-19 OTC stimulant laxatives Methotrexate – new measures Lorazepam (Ativan®) 4mg/ml Solution for injection (Pfizer) shortage Opioids- Risk of dependence and addiction Valproate Other patient safety updates National Patient Safety Alerts COVID-19: Yellow Card reporting including COVID-19 vaccines Reporting patient safety incidents Relevant links & signposting Contact your MSO Summary of key findings from analysis of patient safety incidents reported during Q3 2020 Overall, there was a 19.6% increase in the number of incidents reported during Q3 2020, compared to Q2 2020. Compared to the same quarter in 2019, there was a 43.3% decrease in the number of incidents reported during Q3 of 2020.…

NPA medication safety update (MSO report) Quarter 2 2020 (England)

Superintendent update on the MSO Quarterly report (April- June 2020)

During this unprecedented time we appreciate, you are all extremely busy with a massively increased workload currently. 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. During the coronavirus (COVID-19) pandemic, since March 2020, there has been a significant decrease in the number of patient safety incidents being reported.  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 second quarter of 2020 (Q2) – access the full update here. Included in the medication safety update: Analysis of patient safety incidents reported during Q2 2020 Look alike sound alike (LASA) analysis Impact of COVID-19 pandemic Safe use of emollient skin creams Direct-acting oral anticoagulants (DOACs) increased bleeding risk Medical interventions: sodium valproate, primidos and pelvic mesh implants Valproate Steroid Emergency Card Isotretinoin – reminder of risks and precautions Alfentanil injections – risk of 10 times overdose Priadel (lithium carbonate) modified release 200mg and 400mg supply COVID-19: Yellow Card reporting Reporting patient safety incidents Relevant links & signposting Contact your MSO Summary of key findings from analysis of patient safety incidents reported during Q2 2020.…

NPA medication safety update (MSO report) Quarter 1 2020 (England)

Superintendent update including analysis of incidents reported during Quarter 1 2020 (England).