MSO Quarterly report (October – December 2017) and a summary of patient safety in 2017

29 Jan 2018

Superintendent update on the NPA Medication Safety Officer's Quarterly report - Quarter 4 2017

Dear Superintendent,

I attach my Medication Safety Officer (MSO) report for Quarter 4 of 2017. The report includes two new checklists and top tips related to date-checking and Controlled Drugs (CDs) , as well as guidance to help reduce patient safety incidents involving expired medicines and CDs; this includes best practice for dispensing and recording CDs as well as conducting CD audit checks.

Patient safety: a summary of 2017
There was an overall increase of more than 45 per cent in the number of patient safety incident reports submitted to the NPA, by pharmacies in England, compared to 2016. These reports provide us with vital information and allow us to analyse national trends and share learnings from patient safety incidents on a national level. Therefore, I continue to encourage community pharmacies in England and Scotland to submit patient safety incident reports via the NPA website. For pharmacies in Northern Ireland, reports should be submitted to the Health and Social Care (HSC) Board anonymous reporting form and in Wales, patient safety incidents should be reported via the National Reporting and Learning System (NRLS).

The most common errors reported to the NPA in 2017 were ‘wrong drug’ (24%) and ‘wrong/unclear dose or strength’ (24%) errors. The top three ‘wrong drug’ errors reported in 2017 were:

  • Amlodipine/amitriptyline
  • Atenolol/allopurinol
  • Pregabalin/gabapentin

The top contributing factor reported in 2017 was ‘work and environment’ factors (39%) and ‘no harm’ was the highest reported outcome (67%) in 2017.

Top patient safety topics of Quarter 4 2017
In my role as MSO during Quarter 4 of 2017, I raised a number of important patient safety topics, within my superintendent updates, tackling a range of issues. Patient safety incidents associated with dispensing opioid medicines is a recurring and prominent issue, as highlighted by the NRLS alert released in 2008. The NPA developed a patient safety resource for dispensing opioids, including opioid dispensing top tips, in order to reduce opioid related patient safety incidents.

Valproate and the associated risks of birth defects due to in-utero exposure remain a patient safety priority to the Medicines and Healthcare products Regulatory Authority (MHRA) – the NPA developed a valproate dispensing checklist to assist pharmacy teams with all patient safety aspects when dispensing valproate for pregnant females or women of childbearing potential.

Finally, I raised concerns around antibiotic prescribing errors, following a number of reports received. To assist pharmacy teams to remain vigilant of antibiotic prescribing errors and provide guidance on how to manage such errors, I highlighted a suggested checklist for use when performing a clinical check, along with guidance on use of appropriate clinical resources and raising concerns with prescribers.

Eye products identification checker
Quarter 4 of 2017 showed an increase in the number of errors involving dispensing of combination products against generic and branded prescriptions – products with two or more active ingredients, in particular eye preparations. Therefore, the NPA has developed the ‘Eye products identification checker’ resource, which is designed to support pharmacy teams in dispensing and accuracy-checking generically written prescriptions for eye products.

The resource is comprised of two parts; part 1 – licensed eye products and part 2 – eye devices. The resource also includes the drug class, generic name/active ingredients and strength, brand name (where applicable), formulation, preservative content and shelf life after opening for each product.

NPA Patient Safety Awards 2018 – Best Patient Safety Improvement Team
Finally, I am pleased to announce the first NPA Patient Safety Awards. We are looking to recognise the great patient safety work carried out by pharmacy teams and to crown a winner as the Best Patient Safety Improvement Team 2018! Applications will open in early February 2018 and we are looking for applicants to share their actions, achievements and most significant patient safety results.

The winner will be announced in March 2018 and presented with a certificate and an award to recognise their achievements. Details of the winner’s patient safety agenda will also be shared across the NPA network.

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

Kind regards,

Leyla Hannbeck MSc, MRPharmS, MBA
Chief Pharmacist