MSO Quarterly report (April – June 2017) including top tips for minimising risk of errors

20 Jul 2017

Superintendent update providing the 2017 Quarter 2 MSO report on findings from NPA Patient Safety Incident report forms received by the NPA.

Dear Superintendent,


I attach my Medication Safety Officer (MSO) report for Quarter 2 of 2017 which includes a summary of the dispensing errors reported to the NPA during the quarter and action points to help minimise the number of errors.


Key findings

  • The two most common error categories reported continue to be ‘dispensing a wrong/unclear dose or strength’ and ‘dispensing the wrong drug/medicine’; the level of incidence of both these types of errors remains at 25%; same as the last quarter
  • The most commonly dispensed ‘wrong strength’ category drugs were lansoprazole and perindopril
  • The most common ‘wrong drug/medicine’ errors reported involved the following:
    • Atorvastatin/Simvastatin
    • Bendroflumethiazide/bisoprolol
    • Pantoprazole/pravastatin
    • Pregabalin/gabapentin
    • Risperidone/ropinirole
  • Work and environmental factors” continues to be the main contributing factor for an incident occurring; there was a six per cent increase in reporting during Q2 2017 to 46% of this as a contributory factor, compared to the last quarter (40%)


NPA shortlisted for prestigious award

During quarter 2, the NPA was shortlisted for the “Best Patient Safety Improvement Team” award as part of the prestigious annual patient safety awards held in July. Following this industry-wide acknowledgement for enhancing effective reporting within community pharmacy, we remain committed to further enhancing reporting and effective learning arising from patient safety incidents. This ensures that a solid patient safety culture is built within pharmacy teams, pharmacists and pharmacy undergraduates.


New patient safety resource – insulin identification checker

I am pleased to announce the launch a new patient safety resource — “Insulin identification checker”, to support pharmacy teams in minimising the risk of dispensing errors involving insulin. Patient safety incidents involving insulin are frequently reported. This resource is intended to help you identify and distinguish between the different types of insulin available and ensure the appropriate product is selected during the dispensing process.


Other patient safety resources

To help support safer dispensing, minimise the risk of dispensing errors, and improve patient safety, the following patient safety resources are highlighted for your use:


In addition, you can view an MSO update webinar presented by myself on dispensing incidents and learnings.


For further information on any of the above, please contact the NPA Pharmacy Services team on 01727 891 800 or email

Kind regards,


Leyla Hannbeck MSc, MRPharmS, MBA
Chief Pharmacist