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Pharmacist safety reports plummet by 43%

A distinct trend towards reduced reporting of patient safety incidents by pharmacies has continued throughout the Covid-19 pandemic, the National Pharmacy Association has said. 

The NPA’s medication safety officer report for August-October 2020, published on February 15, shows that as in the two preceding quarters incident reporting was down significantly on previous years.

In the third quarter of 2020 there was a 43.3 per cent decrease in reports compared to the same period in 2019.

The NPA says that due to the “increased workload and pressure on pharmacy teams due to Covid-10 pandemic… pharmacy teams may not be prioritising reporting of patient safety incidents,” though it acknowledges that other factors could be in play.

In Q3 2020 93 per cent of incidents reported originated in the pharmacy, with two per cent attributed to prescribing errors.

Eight-seven per cent of all incidents involved a dispensing error such as the wrong drug (29 per cent of incidents), wrong strength (27 per cent) or wrong formulation (13 per cent) being given.  

Six per cent of incidents involved medications being ‘mismatched’ to the wrong patient.

Delivery/collection errors accounted for seven per cent of incidents, down slightly on the second quarter of 2020. 

As in previous MSO reports, the majority of incidents resulted in no harm to patients (63 per cent) or a near miss (20 per cent). Twelve per cent resulted in a low degree of harm, while two per cent involved moderate harm, such as once incident where a patient received domperidone instead of donepezil and “suffered from reduced energy and stomach discomfort”. 

Work and environment factors such as time pressure and understaffing continue to be the main driver of patient safety incidents, accounting for 35 per cent of reports, followed by look alike, sound alike errors at 25 per cent. 

However, anecdotal reports to the NPA suggest the number of incidents specifically caused by Covid-19 may have dropped in the third quarter of 2020.

Meanwhile, compared to Q2 there was a six per cent drop in the number of incidents attributed to pharmacists carrying out all steps in the dispensing process themselves.

“Please continue to report, investigate and analyse patient safety incidents and share learnings from them within your pharmacy teams,” the NPA urged contractors.




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