Scotland patient safety incident report: February 2017 – April 2017

Introduction

This is my second patient safety incident report for Scotland since the launch of the NPA online near miss and reporting tool for members in Scotland last November. It covers the reports received between February and April 2017.

NOTICEBOARD

New NPA inhaler identification checker resource

A recurring theme of patient safety incident reports received by the NPA involves incorrect inhalers being dispensed against generic prescriptions. To address this, the NPA has produced a new inhaler identification checker, in order to help dispensing staff identify the different inhalers available and ensure the appropriate inhaler is selected. This resource can be printed and kept in the pharmacy to help reduce the occurrence of such errors.

Updated MHRA valproate resources

The Medicines & Healthcare products Regulatory Agency (MHRA) has issued a Patient Safety Alert and updated its resources regarding the use of valproate in females of childbearing age. The valproate toolkit can be used by healthcare professionals, including pharmacists, to help them communicate the risks of valproate in pregnancy to patients. The toolkit materials can be accessed from the MHRA section of the GOV.UK website.

Frequent errors – common themes

The main themes that emerged in the errors reported from Scottish NPA members during February – April 2017 are:

  • Prescription errors

The wrong dose or strength of medication supplied accounted for nearly a third of all errors. These were caused by various reasons including:

  • GP prescribing dose errors not picked up on checking
  • Incorrect selection of repeat items from PMR
  • Shelf picking errors

Wrong quantity being supplied due to reasons including:

  • Unfamiliar blister strip size – strips of 12 rather than 10s or 14s especially
  • Different from usual pack size – 84s instead of 56s for twice daily dose
  • Split packs – pack not clearly identified as already opened and small tablet strips being hidden in patient information leaflets
  • Contributing factors
  • Contributing factors in this period included medication factors (over a third of reports), training (a fifth of reports) and environment (an eighth of reported errors)
  • Monitored dosage device errors reported were lower than the previous three months at 15% and were due mainly because of standard operating procedures not being followed
  • Degree of harm
  • 43% or errors were deemed to cause no harm
  • 7% low harm
  • 15% moderate harm
  • Other errors involved:
  • Not asking the patient for their address to check against the prescription
  • MDS systems not clearly identifying discontinued medicines
  • Weekly dose medicines prescribed as daily
  • Assuming an item is a repeat prescription when selecting from the PMR
  • Environment factors including the different dispensary routines experienced at the weekend and alsodistractions from the close of day procedures
  • Paracetamol 250mg/5ml suspension prescribing for under 6year olds and paracetamol 250/5ml suspension being used by parents for younger siblings of the patient
  • Similar sounding names of medicines with one item being unfamiliar to staff ‒ for example, hydrocortisone injection picked instead of hydroxocobalamin injection
  • New systems being introduced into dispensary working

Top tips for minimising risk /general action points
Safety culture within the pharmacy
Address any safety issues identified in the pharmacy ‒ carry out a root cause analysis to help identify the cause(s) and take steps to prevent any reoccurrence
Conduct safety huddles and staff meetings ‒ these are a good way to ensure all staff members are kept up-to date with recent patient safety incidents
Implement an open culture where there is a focus on learning, rather than blame
Make it easy to report incidents by bookmarking the NPA Patient Safety Incident Report form
Improve data quality and make reporting matter ‒ incidents that are categorised as ‘Other’ in any of the fields restrict the level of useful analysis of the information
Do not confine reporting to dispensing errors and near misses only – remember the NPA Patient Safety Incident Report form can be used to cover all types of errors from prescribing errors/incidents to adverse effects felt by the patient following use of the medication
Dispensing environment
Keep the physical surroundings as de-cluttered as possible – ensure a cleaning rota is in place
Ensure a separate basket is used for each patient (including members of the same family) to prevent checking against an incorrect prescription or bagging incorrectly
Place fast moving lines in more accessible areas for the convenience of dispensers
Do not dispense or check more than one prescription at one time and do not conduct the final check while distracted