The Pharmaceutical Journal
Vol 279 No 7459 p7
7 July 2007

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A third of patient safety incidents reported within primary care take place in community pharmacies

More than a third of incidents in primary care reported to the National Reporting and Learning System took place in community pharmacies, the Patient Safety Observatory of the National Patient Safety Agency states in its fourth report, published last week (PDF 1.2MB).

In an analysis of incidents recorded from January 2005 to June 2006, the most common location for incidents in primary care was patients’ homes, followed by community pharmacies.

The third largest number of incidents (some 11.5 per cent) took place in general practice. However, the report acknowledges that reporting of all incidents in general practice to the NRLS is generally low.

Most community pharmacy errors related to the preparation or dispensing of medicines. “This is unsurprising,” the reports says, “as this activity still constitutes most of a community pharmacist’s work, although this may change as new roles for pharmacists begin to be accepted by [other] professions and their patients.”

Reported incidents suggest that selection errors are common, and may be linked to similar packaging or poor dispensary layout, the report adds.

The report describes seven key priority areas in which the NHS should take action to improve medication safety:

• Increasing levels of reporting and learning from medication incidents

• Implementing NPSA recommendations on safe medication practice

• Improving staff skills and competencies

• Minimising dosing errors

• Ensuring medicines are not omitted

• Ensuring the correct medicines are given to the correct patients

• Documenting patients’ medicine allergy status

The NPSA says that even small improvements in these areas can make a difference to reduce harm to patients, adding that NHS organisations should have quality assurance processes in which chief pharmacists take the lead on improving medication safety.