When two drugs not only look alike but have similar names, it’s no wonder busy pharmacists sometimes make mistakes.
These ‘look-alike, sound-alike’ mistakes make up 29% of all patient safety errors reported to the National Pharmacy Association (NPA) in the first three months of this year. [Note that this link will open a new window with the full PDF].
Pregabalin and gabapentin, amlodipine and amitriptyline, and atenolol and allopurinol are among the chief culprits.
However, the NPA’s Medical Safety Officer Leyla Hannbeck told Chemist and Druggist that the recent classification of pregabalin and gabapentin as Class C controlled drugs should lead to fewer prescriptions and more stringent checks.
A further 11% of all safety incidents are classified as “wrong formulations”. The majority involve inhalers, with mix-ups occurring between dry powder, breath actuated and nasal spray types.
Ms Hannbeck advised pharmacists and staff to use the NPA’s inhaler guide [link opens full PDF in new window] to check which device to dispense.
Delivery driver errors
Other reported errors include those made by delivery drivers failing to follow standard operating procedures.
In one incident, a dog needed a vet visit after eating its owner’s supply of prednisolone 5mg tablets, which had been posted through the letterbox.
While 93% of errors are made by pharmacies, some 5% originate from prescribers.
One patient ended up in hospital with hallucinations after being prescribed double the daily dose of delmosart.
Ms Hannbeck said that such errors had been underreported but showed how “clinical checks made by pharmacists and their vigilance is preventing harm to the patient”.
Overall, 53% of all errors in the report resulted in no harm to the patient – but 34% were classified as ‘near-misses’, and 2% were ‘moderate errors’ which resulted in hospital treatment.
Increase your patient safety with technology
No matter how well trained, experienced and conscientious you and your staff are, pharmacy mistakes can and do happen.
Pharmapod is an easy-to-use, cloud-based platform for recording patient safety errors anonymously. That gives pharmacists the opportunity to review and improve their practices – and reduces the chance of your business adding to the NPA’s patient safety error statistics.
Talk to the Pharmapod team today to find out how our technology can help protect your patients and customers even further.
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By Carla Beaton, Pharmacist and VP of Quality Improvements and Innovations Pharmacists across Canada fill more than 600 million prescriptions every year, and though somewhat
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