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Medication errors

DOACs account for 'notable number' of medication errors

A “notable number” of medication errors involving direct oral anticoagulants (DOACs) occurred in the first quarter of 2019, according to the National Pharmacy Association’s (NPA’s) Medication Safety Officer update for April–June 2019. 

The report, published on 26 July 2019, said that more than 5% of all reported “wrong drug/medicine’ incidents” involved DOACs, with the most common type of incident being rosuvastatin given in place of rivaroxaban, or vice versa.

Pharmacists should consider “separating out these high-risk drugs to a separate DOAC or anticoagulant area of the dispensary to help reduce picking errors”, the report advised, as well as providing educational material when patients are initiated on DOACs.

The report also highlighted that “wrong strength errors” — which make up 27% of all incidents — continue to be made with gabapentin and pregabalin “despite the rescheduling”. These two drugs accounted for 5% of all such incidents.

The major factor contributing to patient safety incidents was “work and the environment”, the report said. Just over a third (34%) of reported incidents identified “time pressures, understaffing and cluttered or poorly organized working environments” as contributory factors to the error reported. 

However, the report also showed that the total number of patient safety incidents had decreased by 19% in spring 2019, compared to the previous three months. 

The update was compiled by Leyla Hannbeck, formerly the NPA’s director of pharmacy and medicines safety officer for all independent pharmacies in England with fewer than 50 branches.

Hannbeck has announced that after ten years with the NPA, and almost five years as medicines safety officer, she is leaving to take up the role of chief executive officer at the Association of Independent Multiple Pharmacies.

Citation: The Pharmaceutical Journal DOI: 10.1211/PJ.2019.20206875

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