MSO Quarterly report (July – September 2017) including top tips for minimising risk of errors

19 Oct 2017

Superintendent update providing the 2017 Quarter 3 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 3 of 2017 which includes a summary of the most common dispensing errors reported to the NPA during the quarter along with top tips to help you when carrying out a root cause analysis. This quarterly report includes an analysis of all reported incidents and learnings shared from community pharmacies; this can be used to meet the national sharing component of the annual patient safety report criterion for the quality payments scheme.

Quality payments scheme

With the second review point for the quality payments scheme fast approaching on Friday 24 November, I would like to remind you of the NPA support available to help you meet this patient safety criterion, for the November review point, if not previously claimed.

If you missed the patient safety webinar that I presented on meeting this quality criterion, you can access it on the NPA website. The NPA resources available to help you complete this criterion include a template annual safety report, together with guidance and worked examples to help you complete your own report.

New NPA standard operating procedures (SOPs)

I am pleased to announce that the NPA has developed a new portfolio of SOPs designed to ensure the safe and effective running of the pharmacy. Each SOP contains patient safety elements to support in the prevention of patient safety incidents and potential patient harm. Please remember that the SOPs are to be used in conjunction with the two supporting documents:

  1. Delegation of responsibilities
  2. Pharmacy team declaration

Dispensing opioid medicines

I would like to draw your attention to the importance of ensuring safe and effective dispensing of opioid therapy. This topic has been a recurring issue for many years and associated with many patient safety incidents and numerous deaths. A National Reporting and Learning System (NRLS) alert issued in 2008 highlighted the importance of reducing dosing errors and the potential implications of unsafe doses.

We have produced a patient safety resource for dispensing opioids that can be downloaded on the NPA website.

The reported patient safety incidents related to opioid medicines have highlighted key learning points which include:

  • Ensuring appropriate doses are prescribed
  • The need to identify patients at increased risk of respiratory depression or QT interval prolongation such as those taking multiple medicines
  • Increasing awareness of dose equivalence of different opiates (where applicable)
  • Increasing awareness of alternatives to opioid medicines for managing ongoing pain
  • Implementing methods to reduce the routine prescribing of high doses of opioid medicines, for example supply of prescriptions on a weekly rather than monthly basis
  • Reviewing of pharmacy SOPs for opiate dispensing
  • Becoming familiar with local opioid prescribing guidelines
  • Potential liaising with local prescribers and pain management clinics to discuss the management of complicated cases, including a monthly patient safety meeting to review concerns about medication levels

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