Trends and Contributing Factors in Medication Home Delivery Incidents in Community Pharmacies Before and After COVID-19: A Retrospective Analysis

This study examines medication home delivery incidents reported in community pharmacies before and after the onset of the COVID-19 pandemic. Medication home delivery incidents are defined as medication errors that occur during the transportation of medication to patients outside the pharmacy through shipping, courier, or pharmacy delivery services. The objective was to analyze trends over time and identify contributing factors to inform patient safety improvements. A retrospective analysis was conducted on medication home delivery incidents reported to a national Community Pharmacy Incident Reporting system, Pharmapod (a Think Research company). Reports from 4091 community pharmacies across 10 provinces and 2 Territories were reviewed, covering the period from January 1, 2019, to January 27, 2022. A total of 156 medication home delivery incidents were identified and analyzed. Of the 156 incidents, 55 (35%) occurred pre-COVID and 101 (65%) post-COVID. The most frequent incident type was delivery to the incorrect patient, which decreased from 52.8% to 32.7%. In contrast, privacy breaches increased significantly from 29.2% to 41.6%. Contributing factors include staffing distribution, lack of quality control or independent checks, environmental distraction, operational workflow gaps, and insufficient staff training. Medication home delivery incidents increased following the onset of the COVID-19 pandemic, revealing emerging safety risks in pharmacy delivery practices. The shift in incident types and contributing factors highlights the need for improved verification protocols, enhanced privacy protections, and dedicated staff training. As home delivery services continue to expand, these findings underscore the importance of system-level interventions to safeguard medication safety in the community pharmacy setting.