NPA medication safety update (MSO report) Quarter 3 2020 (England)

15th February 2021

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

Medication Safety update presenting our analysis of patient safety incidents reported during the third quarter of 2020 (Q3) – access the full update here.

In the NPA Q3 2020 medication safety update:

  • Analysis of patient safety incidents reported during Q3 2020
  • Look alike sound alike (LASA) errors analysis, including trends in gabapentin and pregabalin errors
  • Controlled Drug incidents and COVID-19
  • OTC stimulant laxatives
  • Methotrexate – new measures
  • Lorazepam (Ativan®) 4mg/ml Solution for injection (Pfizer) shortage
  • Opioids- Risk of dependence and addiction
  • Valproate
  • Other patient safety updates
  • National Patient Safety Alerts
  • COVID-19: Yellow Card reporting including COVID-19 vaccines
  • Reporting patient safety incidents
  • Relevant links & signposting
  • Contact your MSO

Summary of key findings from analysis of patient safety incidents reported during Q3 2020

  • Overall, there was a 19.6% increase in the number of incidents reported during Q3 2020, compared to Q2 2020.
  • Compared to the same quarter in 2019, there was a 43.3% decrease in the number of incidents reported during Q3 of 2020.
  • COVID-19 – although the reporting platform does not allow selection of COVID-19 as being a contributing factor, 2.5% of incidents reported included COVID-19 work pressures as other important factors contributing to incidents. This is a 7.8% reduction from Q2 2020.
  • 93% of incidents reported originated from the pharmacy.
  • 2% of errors reported were prescribing errors.
  • The most common type of incident reported during Q2 was ‘dispensing error’, which accounted for 87% of all reported incidents.
  • Delivery/collection errors accounted for 7% of the incidents reported; a decrease of 3% since Q2 2020.
  • The main categories of errors reported were those involving medication errors such as wrong drug, strength or formulation, these accounted for 69% of errors reported – this is a 2% increase from Q2 2020.
  • The degree of harm caused to patients reported as ‘none’ (63%) and ‘near miss’ (23%) continues to make up the majority of the report. There were no incidents reported in Q3 which resulted in ‘severe harm’ or ‘death’
  • There was a 6% decrease in the number of errors reported which involve pharmacist self-checking compared with Q2 2020. This accounted for 7% of errors reported.
  • The main contributing factor continues to be ‘work and environment factors’ (35%) and LASA (26%).
  • LASA errors — 3% of all reported LASA errors involved gabapentin and pregabalin.

Methotrexate – new measures to reduce risk of fatal overdose
Following a review of methotrexate by the MHRA and the European Medicines Agency (EMA), recommendations have been made to mitigate the risk of these errors occurring. Errors leading to patients taking more than the intended dose of methotrexate have been identified at all stages in the treatment pathway. The recommendations are therefore split into three key areas:

  • Prescribing
  • Changes to instructions and packs
  • Educational materials and patient cards

Access the full MHRA update including educational materials and patient cards:


NPA support

  • Based on the update for methotrexate, we have produced a new SOP which sets out the process to be followed when supplying methotrexate access this here 

Contact the NPA Medication Safety Officer (MSO)
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: