NPA medication safety update (MSO report) Quarter 1 2021 (England)

27th October 2021


Medication Safety update presenting our analysis of patient safety incidents reported during the first quarter of 2021 (Q1) – access the full report here

In the NPA Q1 2021 medication safety update:

  • Analysis of patient safety incidents reported during Q1 2021
  • Look alike sound alike (LASA) errors analysis
  • Use of chloramphenicol eye drops in children under two years of age
  • Lithium- new SOP and guidance for monitoring during COVID-19
  • Incident reporting- new SOP and near miss log including the professional duty of Candour
  • Medicines in pregnancy- valproate registry
  • Dispensing prescriptions for children
  • Learn from patient safety events (LFPSE) Service
  • COVID-19: Yellow Card reporting including COVID-19 vaccines
  • Reporting patient safety incidents and professional duty of candour
  • Relevant links & signposting
  • Contact your MSO


Summary of key findings from analysis of patient safety incidents reported during Q1 2021

  • Overall, there was a 6% decrease in the number of incidents reported during Q1 2021, compared to Q4 2020.
  • 95% of incidents reported originated from the pharmacy
  • 3% of errors reported were prescribing errors – this is an increase of 1% compared to the number of incidents reported during Q4 2020
  • The most common type of incident reported during Q1 was ‘dispensing error’, which accounted for 85% of all reported incidents.
  • Delivery/collection errors accounted for 9% of the incidents reported; this is the same as Q4 2020.
  • The main categories of errors reported were those involving medication errors such as wrong drug/medicine, strength or formulation, these accounted for 67% of errors reported – this is a 1% increase from Q4 2020
  • The degree of harm caused to patients reported as ‘none’ (65%) and ‘near miss’ (20%) continues to make up the majority of the reports.
  • There was a 5% decrease in the incidents involving self checking compared to Q4 2020. This accounted for 7% of errors reported.
  • The main contributing factor continues to be ‘work and environment factors’ (41%) and LASA (22%).
  • LASA errors — 2% of all reported LASA errors involvedgabapentin and pregabalin.


Important reminder

During the coronavirus (COVID-19) pandemic, since March 2020, there has been a significant decrease in the number of patient safety incidents being reported.  During this unprecedented time, we appreciate you are currently extremely busy with a massively increased workload. Pharmacies have had to adjust to new ways of working due to the COVID-19 pandemic.  However, patient safety incidents may occur in the course of your practice.

  • Please continue to manage and report all patient safety incidents in line with your pharmacy process
  • This includes completing the recording of the incident details carefully and fully


NPA patient safety resources

The full range of the NPA patient safety resources can be accessed on the NPA website:


Please contact the Pharmacy Services team for further advice and support: