NPA medication safety update (MSO report) Quarter 1 2020 (England)

29 Jun 2020

Superintendent update including analysis of incidents reported during Quarter 1 2020 (England).

During this unprecedented time we appreciate, you are all extremely busy with a massively increased workload currently. Pharmacies have had to adjust to new ways of working due to the COVID-19 pandemic.  However, patient safety incidents may occur in the course of your practice. During the coronavirus (COVID-19) pandemic, since March 2020, there has been a marked decrease in the number of patient safety incidents being reported.  It is important to continue to manage and report all patient safety incidents in line with you pharmacy process. This includes completing the recording of the incident details carefully and fully.

Medication Safety update presenting our analysis of patient safety incidents reported during the first quarter of 2020 (Q1) – access the full update can be accessed here.

Included in the medication safety update

  • Analysis of patient safety incidents reported during Q1 2020
  • Look alike sound alike (LASA) analysis
  • COVID-19: Drug monitoring
  • COVID-19: Medicines safety
  • Delivery of medicines
  • Ranitidine supply
  • COVID-19: Valproate Pregnancy Prevention Programme – temporary changes
  • Medicines compliance aid discontinuation leading to compliance issues
  • COVID-19: Yellow Card reporting
  • Reporting patient safety incidents
  • Relevant links & signposting
  • Contact your MSO

Summary of key findings from analysis of patient safety incidents reported during Q1 2020

Overall, there was a 3.34% increase in the number of incidents reported during Q1 2020, compared to Q4 2019. Compared to the same quarter in 2019, there was a 13.9% decrease in the number of incidents reported during Q1 of 2020.

  • 92% of incidents reported originated from the pharmacy.
  • 4% of errors reported were prescribing errors – this is a 2% increase from Q4 2019.
  • The most common type of incident reported during Q1 was ‘dispensing error’, which accounted for 81% of all reported incidents.
  • Delivery/collection errors accounted for 7% of the incidents reported; an increase in 1% since Q4 2019.
  • The main categories of errors reported were those involving medication errors such as wrong drug, strength or formulation, these accounted for 60% of errors reported – this is a 6% decrease from Q4 2019.
  • The main categories of errors reported were those involving medication errors such as wrong strength (22%), drug (26%) or formulation (12%)
  • Mismatching patients or mismatching between patient and medicine accounted for 15% of errors reported. This is a 6% increase from Q4. The full report includes suggested actions for pharmacy teams to reduce these types of errors.
  • The degree of harm caused to patients reported as ‘none’ (60%) and ‘near miss’ (27%) continues to make up the majority of the report. There were no incidents reported in Q1 which resulted in ‘severe harm’ or ‘death’.
  • There was a 4% decrease in the number of errors reported which involve pharmacist self-checking compared with Q4 2019. This accounted for 11% of errors reported.


LASA errors

In addition to the LASA errors highlighted as high risk by NHS Improvement, 4% of all reported LASA errors involved gabapentin and pregabalin. The reclassification of these medicines as Schedule 3 Controlled Drugs (CDs) in April 2019 has raised more awareness of their reporting. However, even in Q1 of 2020 the trend continues and a significant amount of incidents reported involve these medicines.

COVID-19: Valproate pregnancy prevention programme – temporary changes

The MHRA has issued temporary guidance for management of the Valproate Pregnancy Prevention Programme (PPP) during the coronavirus (COVID-19) pandemic to assist specialists in initiating valproate in female patients, undertaking annual reviews, and pregnancy testing procedures during the COVID-19 pandemic. Read further details in the update.


Contact your Medication Safety Officer (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.

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.

Keep up-to-date with the latest news, information and NPA guidance on coronavirus (COVID-19):