Study analyzes nearly 100,000 medical errors made at Nova Scotia pharmacies

A new report has analyzed nearly 100,000 medical errors made at Nova Scotia pharmacies, 928 of which were linked to patient harm across the province.

The study was published in CMAJ Open on Tuesday, based on information collected at 301 community pharmacies between October 2010 and June 2017. The research revealed a variety of incidents that compromised patient safety, including the dispensing of incorrect drugs, dosages or quantities.

But the major takeaway, says the Nova Scotia College of Pharmacists, is that 82 per cent of reported errors were caught and corrected before they ever reached the patient.

READ: Nova Scotia lawsuit over death by alleged prescription error to proceed

“Now that the Nova Scotia College of Pharmacists has baseline data, we can use this to develop and evaluate solutions,” said registrar Bev Zwicker in a press statement responding to the study’s release.

“We are committed to sharing our learnings and working collectively with community pharmacies and stakeholders to further enhance the safety of pharmacy care provided to Nova Scotians.”

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The study was conducted by researchers at SafetyNet-Rx, the Institute for Safe Medication Practices Canada and Dalhousie University, among others, and is believed to be the first analysis of its kind in North America. It identified a grand total of 131,031 incidents reported by community pharmacies, 98,097 of which were described as “quality-related events” — or medication errors that either reach the patient, or are intercepted and corrected before dispensing.

Roughly 30 per cent of those errors involved incorrect dosages or frequencies, followed by incorrect strengths or concentrations at 20.2 per cent, and incorrect drugs at 19.9 per cent. Just under one per cent were tied to patient harm, including adverse drug reactions.

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Study co-author and Dalhousie University professor James Barker said Nova Scotians should be reassured by those numbers, which reveal that the province’s system of reporting pharmaceutical errors is working in their favour. Nova Scotia pharmacies are required under law to report medication errors that reach patients, following regulatory changes in 2010.

“Very few these errors get to the patient and even fewer of those cause harm,” he said.

“What the pharmacists know is that by reporting errors, they can learn from them and they are actively involved in learning from the errors and incorporating that learning into the work that they do.”

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The data for the study was collected from the province’s Community Pharmacy Incident Reporting system. Barker and the research team have already begun studying how pharmacists use that reporting system, in order to make improvements.

The Nova Scotia College of Pharmacists has also pledged to make the prevention and reporting of adverse drug reactions a focus of community pharmacy inspections in 2019.

“With respect to adverse drug reaction reporting, it’s really about a lack of information that contributes to adverse drug reactions,” said Zwicker.

“So taking steps to make sure that pharmacists have all the information that they need, so they can make the right decision when they’re determining whether or not it’s appropriate to dispense medication for a patient, is critically important.”

According to the researchers, community pharmacies in Nova Scotia dispense about 13 million prescriptions each year and more than 600 million Canada-wide.