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Patient safety errors increase by over 60% within four months, NPA reports

By Beth Gault

22 Aug 2018

The number of errors reported to the National Pharmacy Association (NPA) increased by 64% between March and June this year, the organisation has reported.

The ‘reports almost doubled in June compared to April and May, the NPA medication safety officer’s (MSO) patient safety report, published this week, revealed.

In nearly half of the cases, the main reason for the error was attributed to ‘work and environment factors’, which contributed to work load and time pressures. This number increased significantly from the first quarter in the year, from 4% to 45% in quarter two.

The report highlighted dispensing errors involving breach of confidentiality made up 8% of incidents following new data protection rules the General Data Protection Regulation (GDPR), which came into force in May 2018.

Errors included handing out medication to the wrong patient due to similar names, bagging up medication and attaching the repeat prescription slip in another bag for a different patient and getting names and addresses mixed up on medicine labels.


‘Robust procedures’ needed

The NPA’s director of pharmacy Leyla Hannback said: ‘It is important to reiterate that pharmacy teams are required to have robust procedures in place for investigating and reporting data breaches.’

‘I recommend every pharmacy maintains a log of all data breaches, including when the data breach occurred and action taken, as required under GDPR.’

Ms Hannbeck continued: ‘Sometimes pharmacists just want to seek our advice for reassurance and guidance and when we receive these types of queries, we always remind them to use our online platform to report.

‘The implementation of GDPR…could also be one of the main contributing factors for pharmacy contractors to report all types of incidents.

‘Pharmacy teams also have more knowledge around GDPR through webinars, resources, workshops and this could have prompted more frequent use of our platform.

‘Work and environment factors has always continued to be the main contributing factor regardless of the increase in reports or not and therefore we are unable to provide a definitive explanation.’


Types of error

The greatest number of errors were made by giving the wrong or unclear dosage or strength of medicine, accounting for 29% of mistakes. This was followed by giving the wrong medicine in 23% of reported errors.

Over 50% of errors caused no harm to patients. However, 4% caused moderate harm, including several cases where patients had to attend hospital.

The cases of hospitalisation included the pharmacist giving out the wrong insulin, meaning the patient suffered from a hypoglycaemic episode during the night. In another case, a patient was given the wrong dose of Asacol tablets that resulted in hospitalisation.

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