Number of reported medication-related incidents falls to lowest level since 2014/2015

In 2020/2021, NHS organisations in England reported the lowest number of medication-related safety incidents in six years, an analysis of NHS England data has revealed.

The National Patient Safety Incident Report (NaPSIR), published on 28 September 2021, showed that NHS organisations across primary and secondary care reported 187,670 medication-related patient safety incidents between April 2020 and March 2021, during the COVID-19 pandemic.

The analysis of past NaPSIRs, carried out by The Pharmaceutical Journal, revealed that the figures from 2020/2021 were the lowest recorded since 2014/2015, when 175,459 such incidents were reported between April 2014 and March 2015.

Between 2014/2015 and 2019/2020, the number of reported medication-related incidents increased year-on-year, to 222,514 in 2019/2020.

NaPSIRs show the number of incidents reported to the National Reporting and Learning System (NRLS), which has been running since 2003.

According to the NaPSIRs, there were 2,971 medication-related incidents reported from community pharmacies in 2020/2021, compared with 3,763 in 2019/2020. In 2014/2015, 1,642 such incidents were reported from community pharmacy.

Commenting on the data, Alison Smith, lead pharmacist and medicines safety officer at Worcestershire Acute NHS Trust, said: “It is generally accepted that the decrease in reporting for 2020/2021 is due to the [COVID-19] pandemic.”

She added that the increase in reporting in previous years has been associated with “the introduction by NHS England of the Medicines Safety Officer (MSO) role in 2014”, which was designed at the time to support local medication error reporting and learning.

Tony Jamieson, clinical improvement lead in the medicines safety improvement programme at NHS England and NHS Improvement, said: “The lower number of reports associated with medicines in 2020/2021 has not followed the trend over previous years and no-one would doubt that 2020/2021 was an atypical year.

“We have recently looked at the role of MSOs across England and recognised the critical role they play in both learning from events and Yellow Card reporting.

“We want to see the MSO role go from strength to strength so that MSOs can take a proactive approach to medicines safety as the NHS meets the current and future challenges.”

Jasmine Shah, medication safety officer at the National Pharmacy Association, added that the COVID-19 pandemic also resulted in a “significant drop” in the number of medication incidents reported from community pharmacy “as pharmacies adjusted to the unprecedented situation and new ways of working”.

“We have reminded our members how important it is to continue to manage and report all incidents in line with their pharmacy processes and to record incident details fully.

“We have seen the number of reports pick up during 2021, though not yet to pre-pandemic levels,” she said.

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