NPA medication safety update (MSO report) Quarter 4 2019 (England)

4th March 2020

The NPA is pleased to publish its fourth medication safety update/Medication Safety Officer’s (MSO) report on patient safety incidents covering the fourth quarter of 2019 (Q4). The full update can be accessed here.

Key findings from analysis of patient safety incidents reported during Q4 2019

Overall, there was a 17% decrease in the number of incidents reported during Q4 2019, compared to Q3 2019. We apologise for the typographical error which previously reported this as a 25% decrease. Compared to the same quarter in 2018, there was a 7% increase in the number of incidents reported during Q4 of 2019. Overall, there was a 32% increase in the number of patient safety incidents reported during 2019 compared to 2018.

  • 95% of incidents reported originated from the pharmacy
  • 2% of errors reported were prescribing errors – this is a 3% decrease from Q3

Prescribing errors often remain underreported due to pharmacy teams liaising with the prescriber directly. It is very important that such errors are recognised and all prescribing errors are reported. This reporting allows trends to be identified resulting in valuable learning outcomes for the pharmacy teams.

Example of a prescribing error where technology may have been a contributing factor

A prescription was presented for Ofloxacin ear drops 0.3%, an unlicensed preparation. This preparation concerned the pharmacist who contacted the prescribing doctor to discuss the appropriateness of prescribing an unlicensed product. During the conversation, it transpired that the doctor had intended to prescribe Otomize ear spray however had selected the incorrect item from the drop-down-list on the prescribing system.

Medication error categories and incidents reported during Q4 of 2019

  • The main categories of errors reported were those involving medication errors such as wrong strength (27%), drug (27%) or formulation (12%)
  • There has been multiple ‘wrong drug/medicine’ and ‘wrong formulation’ incidents reported during this quarter involving combination products. Incident reports highlighted the correct first active ingredient but the incorrect second active ingredient. The full report includes a focus on combination products and suggested actions for pharmacy teams to prevent/reduce these types of errors.
  • Mismatching patients or mismatching between patient and medicine accounted for 9% of errors reported. This is a 0.2% increase from Q3. The full report includes suggested actions for pharmacy teams to reduce these types of errors.

Degree of harm
The degree of harm caused to patients reported as ‘none’ (63%) and ‘near miss’ (24%) continues to make up the majority of the report. There were no incidents reported in Q4 which resulted in ‘death’.

Example of a similar packaging – Controlled Drug near miss

A prescription was presented for loperamide capsules 2mg. During the dispensing process phenobarbital, a Schedule 3 Controlled Drug (CD), was selected and dispensed. The pharmacist picked up this incident and the wrong medication did not reach the patient. Upon investigation, it transpired that the phenobarbital was selected from the loperamide shelf in error, where it had been stored away in error as the packaging of both medication was identical. Similar packaging was the primary contributing factor for this near miss.

There was no change in the number of errors reported which involve pharmacist self-checking compared with Q3. This accounted for 10% of errors reported.

LASA errors
In addition to the LASA errors highlighted as high risk by NHS improvement, 5% of all LASA errors involved gabapentin and pregabalin. The reclassification of these medicines as schedule 3 controlled drugs may have raised awareness of reporting and may be contributing to the large number of incidents reported where these two medicines have been mixed up. This report also highlights other LASA errors that have been frequently reported in Q4 and throughout 2019.

Yellow card reporting

The Yellow Card Scheme is an essential tool that the MHRA uses to monitor the safety of medicines, medical devices and herbal or complimentary medicines. It is crucial to report problems with these products in order to improve patient safety by identifying issues such as side effects, as well as defective and counterfeit medicines or medical devices.

Contact your MSO

The NPA holds the role of Medication Safety officer (MSO) for all independent community pharmacies in England with fewer than 50 branches. If you operate an independent community pharmacy, and there are fewer than 50 branches in your pharmacy chain, then the NPA is your MSO. Jasmine Shah, NPA Head of Advice and Support Services, currently holds the role of MSO at the NPA.

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 here.

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