Medication Safety Officer report Q4 2021

Medication Safety update presenting our analysis of patient safety incidents reported during the second quarter of 2021 (Q4) – access the full report 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

Number of patient safety incidents during Q4 of 2021

Overall, there was a 15% decrease in the number of incidents reported during Q4 2021, compared to Q3 2021. Please continue to report, investigate and analyse patient safety incidents, and share learnings from them within your pharmacy teams.

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

 

 

 

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:

• Tel: 01727 891800 (9am-6pm Mon-Fri, 9am to 1pm Sat)
• Email: [email protected] (anytime)

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 [email protected].

• 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.