Research Assistant/Student Saint Mary's University, Halifax, Canada Calgary, Canada
Background: The study centers on examining medication incidents (MIs) that occur in Canadian community pharmacies (CoPh) and the new challenges imposed by the unique context of the COVID-19 crisis. This study specifically identifies the occurrence of medication home delivery incidents during this period. Medication incidents (MIs) are defined as medication errors that reach the patient (e.g., incorrect drug, doses, quantity), in addition to medication errors that are intercepted before dispensing (i.e., near misses). Medication home delivery incidents are medication errors that occur during the conveyance and transportation of medication to patients. They include those that occur within the pharmacy such as direct pick up at the pharmacy, and those that occur outside the pharmacy such as through shipping or courier services.
Objectives: To provide clarity on the occurrence and causes of medication home delivery incidents, as well as the impact before and after the COVID-19 crisis started, and identify strategies to prevent them.
Methods: A retrospective analysis was conducted on medication incidents reported into a national Community Pharmacy Incident Reporting system, Pharmapod (a Think Research company). The sample included 4091 community pharmacies from 10 provinces and 2 territories between January 1, 2019 and January 27, 2022. We performed a descriptive analysis on these incidents with respect to the patient outcomes (level of harm), medication system stages, contributing factors and frequency of reporting before and after the start of the Covid-19 pandemic (March 2020).
Results: We identified a total of 3576 incidents reported over the study period. 156 occurred during delivery to patients addresses. Overall, 55 (1%) were reported pre-Covid and 101 (2.8%) post-Covid. The most frequent types/categories of delivery incidents were the incorrect patient cases and the privacy breach cases. The most occurring contributing factors were staff distribution, lack of quality control or independent checks, environmental distraction, operational process issues and lack of staff education.
Conclusions: The present study found that medication home delivery incidents increased during the COVID-19 pandemic. The major trends of occurrence of the incidents were errors caused by the delivery person and incidents caused by errors from within the pharmacy that affected the quality of safe medication home delivery. Given the increase in the use of home delivery, the results suggest that there are new challenges and barriers to safety in this context. This analysis provides valuable information to guide quality improvement initiatives to strengthen medication safety in community pharmacies during these challenging times and beyond.
