Cluttered shelves were among the factors causing pharmacists to dispense the wrong strength medicine in Scotland in recent months, according to the latest Patient Safety Report.

As an article in the Pharmaceutical Journal explains, self-checking prescriptions and putting split strips of tablets back into the wrong box also contributed to ‘wrong strength’ cases, which made up 23% of patient safety incidents reported by independent community pharmacies to the National Pharmacy Association (NPA) between October 2018 and March this year.

The most common error category continued to be ‘wrong drug/medicine’, accounting for 32% of all cases, while 19% of mistakes were due to a mismatch between patient and medication, 13% to issues with medical compliance aids, and 10% to issues with deliveries to patients.

Introducing the report, NPA Director of Pharmacy Lelya Hannbeck said: “It is concerning to see certain error types continuing to occur despite being well publicised and highlighted in previous reports, which also included suggested ways of preventing such errors.”

Look-Alike, Sound-Alike Errors

Hannbeck cited mix-ups between ‘look-alike sound-alike’ (LASA) items and delivery driver errors as examples.

In one case, allopurinol was dispensed instead of atenolol, resulting in significant changes to the patient’s heart rate and blood pressure.

Fortunately, cases causing ‘moderate harm’ accounted for just 6% of all patient safety incidents, with ‘low harm’ being recorded in 10% of cases and ‘no harm’ in 84%.

The report advises avoiding errors by referring to NPA resources, including standard operating procedures for drivers and a list of the most common LASA mix-ups.

Pharmacy Safety Culture

In addition, the report contains top tips for improving safety culture within the pharmacy.

These include:

  • Carrying out a root cause analysis to identify the reasons behind safety issues
  • Conducting safety huddles and staff meetings to keep staff up to date
  • Implementing a ‘just’ culture focusing on learning rather than blame or punitive measures
  • Taking steps to improve reporting of errors to the NPA

Pharmapod – Enhancing Safety Through Recording Errors

In the pressurised atmosphere of a busy pharmacy, mistakes do occur. The Pharmapod platform makes it simple for your pharmacy to record medication errors, so you can implement a learning culture and reduce the number of patient safety incidents.

Data is anonymised and shared globally, meaning that your pharmacy is contributing to worldwide learning and improvements in patient safety.

Call the Pharmapod team today to discuss how the platform can help your pharmacy team boost their safety and efficiency.