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NPA: Work and environment factors behind a third of dispensing errors in 2019

By Costanza Pearce

29 Apr 2019

Work and environment factors accounted for a third of patient safety incidents in the first quarter of 2019, the National Pharmacy Association (NPA) has revealed.

The NPA’s medicines safety officer (MSO) report, published on Thursday (25 April), found that time pressures, distractions and increased staff turnover were behind 34% of errors.

The Pharmacist has asked the NPA for clarification on how many errors in total were made during this time period.

NPA director of pharmacy Leyla Hannbeck is the MSO for all independent community pharmacies in England with fewer than 50 branches.

Commenting on the report’s findings, Ms Hannbeck said: ‘[Errors] mainly occurred due to time pressures where pharmacists and pharmacy teams were “rushing” to complete prescriptions and not paying full attention and due to increased staff turnover, resulting in inappropriate skill mix and staff still undergoing training – leading to the pharmacist to self-check more prescriptions.’

Look-alike-sound-alike (LASA) errors represented 29% of patient safety incidents, such as amlodipine being mistaken for amitriptyline, according to the report.


‘Historically underreported’


Ms Hannbeck said community pharmacies had reported 29% more prescribing errors this quarter than they had in the same period the previous year, although ‘such errors have historically been underreported’, she pointed out.

The report found that pharmacy errors were the cause of 93% of patient safety incidents, with a third of incidents (33%) being the wrong medicine being dispensed and a fifth (21%) the dispensing of the wrong strength.

Prescriber errors accounted for 5%, representing a 3% increase compared to the last quarter of 2018.

A failure to communicate dosage increases during treatment, prescribing medicines that patients were allergic to and not following pharmacy or patient prescription requests were the main reasons for prescriber errors, according to the report.

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