Summary of the example
The Community Pharmacy Patient Safety Group (CPPSG) is a network of Medication Safety Officers (MSOs) from the 18 largest community pharmacy chains and from the National Pharmacy Association, who represent independent pharmacies. The group brings commercial competitors together to openly share and learn to drive patient safety improvement across the sector.
In England alone, around 70 million prescriptions dispensed in the community are for the medicines considered to be the highest risk Look-Alike, Sound-Alike (LASA) combinations. Errors involving LASA medicines have often featured in the ‘share and learn’ sessions at CPPSG meetings, and the MSOs frequently share best practice and risk-minimisation measures that have been implemented well in their own organisations.
Using information from the MSOs, and resource examples from Boots UK, a series of one-pagers have been created to support frontline pharmacy teams in learning and talking about these risks.
To select the LASA pairs featured in our resources, we chose those identified by NHS Improvement from the NRLS data. These five pairs are deemed to be both the most likely to be mixed up and the most likely to cause harm, so by focusing on these medicines, we hope to maximise our impact on improving patient safety outcomes.
Why we think it’s important
The existence of similar looking and sounding names of medicines is one of the most common reasons for medication errors occurring and is a concern around the world. It is explicitly recognised in the WHO Medication without Harm Global Patient Safety Challenge.
These medicines (amlodipine and amitriptyline, atenolol and allopurinol, azathioprine and azithromycin, carbamazepine and carbimazole, and propranolol and prednisolone) are deemed to be the highest risk LASA combinations due to the likelihood of their occurrence and the magnitude of harm that could be caused should they be mistakenly selected for one another. There have been tragic examples of fatal patient safety incidents involving combinations of these high-risk LASA medicines. It is imperative that healthcare professionals receive information in a supportive manner to ensure they can review their own procedures and deliver excellent patient care.
Our work is unique, given that similar resources aimed at pharmacy teams and wider healthcare professionals are not readily available. Our one-pagers are freely available to download from our website so they can be accessed and used by different healthcare professionals working in a range of healthcare settings across the UK and further afield.
Learn more about the example
Aims and objectives of the work
There is no one-size-fits-all solution to preventing patient safety incidents, and often measures put in place to reduce specific risks can become less effective over time. Therefore, it is crucial to create up-to-date and engaging resources to ensure that learning is refreshed. With frequent staff turnover and use of locums in pharmacy, clear messaging is particularly important.
The MSOs recognise that it is probably impossible to eliminate all errors in a busy dispensary which requires human input. Our ambition was to raise awareness and reduce the occurrence of the highest risk errors, thus improving patient care. Some MSOs even classified these specific errors as ‘never events’ in their pharmacies.
The aim of our work was to encourage open and honest sharing about patient safety. It is important to communicate messages to healthcare professionals in a positive and supportive way, while still conveying the seriousness of potential harm.
Through our MSO network we will continue to monitor the number of errors involving the high-risk LASA combinations featured in our resources and will share the information to support continuous improvements. Although we cannot fully attribute incident reduction to the use of our one-pagers, they form an important element of a multifaceted approach.
The LASA medicines featured in our resources are those deemed by NHS Improvement to be the top combinations by likelihood and harm caused, identified using NRLS data. These pairs also feature in the LASA criterion in the Pharmacy Quality Scheme which forms part of the Community Pharmacy Contractual Framework.
The fundamental goal in creating the LASA one-pagers was to stimulate conversation and action at individual pharmacy level to minimise the likelihood of LASA dispensing errors.
The MSOs on the group shared their clinical expertise to inform the resources’ content and the posters were then designed inhouse by the Company Chemists’ Association. This collaborative approach helped ensure that the resources were concise and informative and input from pharmacists across the sector was essential to ensure the resources had maximum impact.
The MSOs, who cover the entire community pharmacy network, disseminated the resources to support regular pharmacy-level safety discussions. We have also worked closely with NHS bodies and the Pharmaceutical Services Negotiating Committee (PSNC) to reach as many other pharmacy professionals as possible, including in other settings. The PSNC published a news story encouraging teams to use our resources and they also shared the resources with their 9,000 Twitter followers.
Evidence of engagement at a local level was seen through Local Pharmaceutical Committees’ (LPCs) sharing of the resources, including through Twitter, Facebook and newsletters. We’ve had fantastic feedback from LPCs, including one Chief Executive who referred to the one-pagers as “top quality resources, essential for all the pharmacy team”.
We are welcoming feedback from pharmacy teams using the resources, and will update them accordingly, to ensure that their positive impact on patient safety persists.
Quality improvements across pharmacies will have a knock-on positive impact on patients. Any incidents involving these medicines are particularly high-risk and likely to cause significant harm, therefore the positive impact is one of a preventative nature. This also has a significant value contribution for the NHS and pharmacy organisations in minimising the likelihood of patient hospitalisation and potentially avoiding litigation costs if an incident results in a patient death.
Our primary goal was to encourage open and honest discussions about LASA errors, and we are confident that our resources will have a long-term positive impact on patient safety.
We launched the resources in February 2019 and in the following three weeks the resources were downloaded over 2,200 times and website traffic increased by 120%. The resources have also had a potential reach of over 100,000 people via Twitter. Success was also seen through positive feedback from key stakeholders including NHS patient safety experts, the PSNC and LPCs. Engagement with these stakeholders demonstrates the potential impact of our work across the whole system. Our resources were positively received by GPhC inspectors who highlighted their important contribution in raising awareness about LASA medicines. Our resources are also included in the Centre for Pharmacy Postgraduate Education’s (CPPE) learning programme on reducing LASA errors, and the CPPSG is the CPPE guardian of this content.
We will continue to monitor data to inform revisions of our resources to ensure they remain up-to-date and effective. We will share our insight in due course.
In the updated Pharmacy Quality Scheme, NHS Improvement included a new LASA combination (rivaroxaban and rosuvastatin) based on the latest NRLS data. We, therefore, updated our resources to account for this, to support pharmacy teams in meeting contractual requirements and continually improving their patient safety practice.
The one-pagers can be downloaded from the Community Pharmacy Patient Safety Group’s website at
https://pharmacysafety.org/2019/02/04/lasa-medicines/. The page also hosts a poster which describes the group’s activity on LASA medicines more generally.
National guidance, data and publications
LASA medicines have repeatedly been cited as a key cause of harm for example by the Medicines and Healthcare products Regulatory Agency and the WHO. However, limited practice guidance currently exists to support healthcare professionals, and particularly community pharmacy teams. This is because very little evidence has been gathered and published to demonstrate what preventative measures are most effective. It is likely that these measures vary from pharmacy to pharmacy dependent on dispensary design and workflow. It is therefore vital that teams agree and commit to local risk management activity. Our one-pagers are the first resources of their kind which are widely available to pharmacy teams to stimulate pharmacy-level thinking, discussion as a team, and action.
The Pharmacy Quality Scheme (PQS) which forms part of the Community Pharmacy Contractual Framework is designed to reward community pharmacies for delivering quality criteria in clinical effectiveness, patient safety and patient experience. One of the patient safety aspects of the latest version of the scheme includes the requirement for pharmacy teams to demonstrate that they actively identify and manage risks associated with high-risk LASA combinations. Inclusion of LASA in PQS demonstrates the recognition from NHS England of the importance of the issue.