MSO Quarterly report (July-September 2018): including updated Incident Reporting Platform, AAI protocol, LASA errors, QP update and valproate treatment

31 Oct 2018

Superintendent update on the MSO Quarterly report (July-September 2018)

Dear Superintendent,

I attach my Medication Safety Officer (MSO) report for Quarter 3 2018 which includes a number of important patient safety updates, top tips to help minimise patient safety incident, and the usual analysis/summary of the most common dispensing errors reported to the NPA during the quarter.


NPA update

Today, I am pleased to announce that the updated MSO Incident Reporting Platform has been launched. This user-friendly platform will help you to complete incident reporting effectively and in a methodological order. There is now an option for the form to be sent to you via email after completion – this will greatly reduce your administrative time as the emailed form can be kept for pharmacy record requirements.

  • An option has been created for selecting ‘Look-alike sound-alike (LASA) errors’ when an incorrect item has been dispensed
  • I would like to remind you not to include any personal data in the form, this includes patient and team member personal details

All MSO quarterly reports can be used to demonstrate evidence of sharing learning as part of the Quality Payment patient safety quality criteria.


MSO report analysis summary for Quarter 3 2018

Errors involving the NHS flu vaccination Advanced Service Patient Group Direction (PGD) 2018/19

Pharmacists must ensure they have fully read and understood what is outlined in the NHS flu PGD and service specification. The following two incidents have been reported:

  1. Fluad® was administered via the subcutaneous route instead of the intramuscular route
  2. A flu vaccine was administered to a breastfeeding woman who is not eligible under the NHS flu PGD

The NPA has a suite of flu resources to support members in delivering both NHS and private influenza vaccination services, including guidance, standard operating procedures and FAQs.

Errors involving insulin aspart solution for injection cartridge 100units/ml 3ml
There are two brands, Fiasp® Penfill and NovoRapid® Penfill®, which can be dispensed against a generically written prescription for insulin aspart solution for injection cartridge 100units/ml 3ml. However, there are differences between the two brands available and therefore, it is important to check the Insulin Passport (or safety card) to identify which specific brand the patient uses.

Errors involving handing out medicines
Approximately 50% of errors reported in Quarter 3 were pertaining to medicines being handed out to patients. This involved:

  • SOPs not being followed by new pharmacy team members
  • Fridge items, especially insulin, handed over to the wrong patient
  • Dispensing from labels and not the prescription
  • Handing out medicines to incorrect patients due to similar sounding patient names

Errors involving over-the-counter (OTC) sales
Two interesting incidents with OTC sales were reported in Quarter 3 of 2018:

  1. Co-codamol tablets 30/500mg was sold OTC on a number of occasions instead of co-codamol tablets 8/500mg due to incorrect stock placement
  2. Derbac M liquid was sold with a dispensing/patient label attached; this had not been removed following a previous prescription which was not collected in time


Adrenaline auto-injectors (AAIs) – protocol 

Following on from my previous superintendent update, please ensure you and your teams follow the Department of Health and Social Care (DHSC) and NHS England interim protocol for dispensing all brands of AAIs 150mcg. Further guidance can be found on the dedicated adrenaline-related NPA webpage, which includes the latest AAI stock update.

Valproate treatment – females of childbearing age

There have been updates from both the Medicines & Healthcare products Regulatory Agency (MHRA) and General Pharmaceutical Council (GPhC), regarding valproate-containing medicines and their serious risks in pregnancy. An NPA member news story has been published following a recent MHRA Central Alerting System alert, giving details how some females patients are still unaware of pregnancy risks and reminding pharmacists to:

  • Ensure the patient is under the Pregnancy Prevention programme (unless opted out)
  • Always supply a patient information leaflet (PIL) with every dispensing
  • Dispense whole packs where possible
  • Discuss valproate risks in pregnancy with the patient each time it is dispensed
  • Have standard operating procedures (SOPs) updated with valproate dispensing steps, and ensure valproate dispensing materials are easily accessible


The GPhC has published a statement reminding pharmacy professionals stating that GPhC inspectors will look to see whether pharmacy professionals are meeting GPhC standards during inspections, by checking whether MHRA guidance is being followed.


Quality Payments Scheme (QPS) – patient safety criteria

The second QPS for 2018/19 was announced in September, with patient safety featuring as a key domain worth a total of 60 quality points. There are now three separate elements to the patient safety criteria each worth 20 quality points:

  1. Completion of a patient safety report at premises level, identifying and managing risks with LASA errors, and uploading to any electronic reporting system and/or the National Reporting and Learning Service (NRLS)
  2. Completion of CPPE Risk Management training module by 80% of registered pharmacy professionals, with a risk review example to be available at premises level
  3. Undertaking a non-steroidal anti-inflammatory drug and gastro-protection audit for patients 65 years and over


LASA errors

To support pharmacy teams, I am pleased to announce the launch of the NPA “Look-alike sound-alike items” resource. The LASA resource identifies commonly mistaken items.

For the ‘wrong drug/medicine’ category in Quarter 3 of 2018, the following LASA errors were reported:

  • Allopurinol – Atenolol
  • Amlodipine – Amitriptyline
  • Gabapentin – Pregabalin
  • NovoMix® – NovoRapid®
  • Pravastatin – Pantoprazole
  • Rosuvastatin – Rivaroxaban


For further information, advice and/or support on any patient safety or pharmacy topic/mater, please contact the NPA Pharmacy Services team on 01727 891800 or email at:

Kind regards,


Leyla Hannbeck MSc, MRPharmS, MBA
NPA Director of Pharmacy
Medication Safety Officer’