NPA medication safety update (MSO report) Quarter 2 2020 (England)

24th October 2020

During this unprecedented time we appreciate, you are all extremely busy with a massively increased workload currently. 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.

During the coronavirus (COVID-19) pandemic, since March 2020, there has been a significant decrease in the number of patient safety incidents being reported. 

  • 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.  

Medication Safety update presenting our analysis of patient safety incidents reported during the second quarter of 2020 (Q2) – access the full update here.

Included in the medication safety update:

  • Analysis of patient safety incidents reported during Q2 2020
  • Look alike sound alike (LASA) analysis
  • Impact of COVID-19 pandemic
  • Safe use of emollient skin creams
  • Direct-acting oral anticoagulants (DOACs) increased bleeding risk
  • Medical interventions: sodium valproate, primidos and pelvic mesh implants
  • Valproate
  • Steroid Emergency Card
  • Isotretinoin – reminder of risks and precautions
  • Alfentanil injections – risk of 10 times overdose
  • Priadel (lithium carbonate) modified release 200mg and 400mg supply
  • COVID-19: Yellow Card reporting
  • Reporting patient safety incidents
  • Relevant links & signposting
  • Contact your MSO

Summary of key findings from analysis of patient safety incidents reported during Q2 2020.

Overall, there was a 44.5% decrease in the number of incidents reported during Q2 2020, compared to Q1 2020. Compared to the same quarter in 2019, there was a 40.6% decrease in the number of incidents reported during Q2 of 2020.

  • 94% of incidents reported originated from the pharmacy.
  • 2% of errors reported were prescribing errors – this is a 2% decrease from Q1 2020.
  • The most common type of incident reported during Q2 was ‘dispensing error’, which accounted for 83% of all reported incidents.
  • Delivery/collection errors accounted for 10% of the incidents reported; an increase of 3% since Q1 2020.
  • The main categories of errors reported were those involving medication errors such as wrong drug, strength or formulation, these accounted for 67% of errors reported – this is a 7% increase from Q1 2020.
  • The degree of harm caused to patients reported as ‘none’ (60%) and ‘near miss’ (25%) continues to make up the majority of the report. There were no incidents reported in Q2 which resulted in ‘severe harm’ or ‘death’.
  • There was a 2% increase in the number of errors reported which involve pharmacist self-checking compared with Q1 2020. This accounted for 13% of errors reported.
  • The main contributing factor continues to be ‘work and environment factors’ (40%) and LASA (21%).
  • COVID-19 – although the reporting platform does not allow selection of COVID-19 as being a contributing factor, 10.3% of incident reported included COVID-19 work pressures as other important factors contributing to incidents

LASA errors
In addition to the LASA errors highlighted as high risk by NHS Improvement, 3% of all reported LASA errors involved gabapentin and pregabalin. The reclassification of these medicines as Schedule 3 Controlled Drugs (CDs) in April 2019 has raised more awareness of their reporting. However, even in Q2 of 2020 the trend continues and a significant amount of incidents reported involve these medicines.

Safe use of emollient skin creams

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What are your key questions on the current hot topics in pharmacy practice?

Don’t miss out on the chance to hear from Jasmine Shah at the NPA Winter Conference 2020. Join us on Monday 9 November between 7.30 – 8.30pm:

If you haven’t already, register your attendance here.

Contact your Medication Safety Officer (MSO)
The NPA holds the role of Medication Safety officer (MSO) for independent community pharmacies in England with fewer than 50 branches.

NPA members
Independent community pharmacies in England, who are NPA members, can contact the NPA MSO through the Pharmacy Services Team at the NPA for further information, advice and/or support on any patient safety or pharmacy topic/matter by:

Independent community pharmacies in England with fewer than 50 branches who are currently not members of the NPA can contact the MSO by email at

  • Include your pharmacy name, ODS code, name of the owner/superintendent pharmacist and their telephone/mobile number, pharmacy’s NHSmail email address.
  • State ‘Non-member MSO query’ in the subject field.

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

For further information please contact the NPA Pharmacy Services team on 01727 891800 or email at: