NPA medication safety update (MSO report) Quarter 3 2019 (England)

19 Nov 2019

Superintendent update on the MSO Quarterly report (July-September 2019)

The NPA is pleased to publish its third medication safety update / Medication Safety Officer’s (MSO) report on patient safety incidents covering the third quarter of 2019 (Q3). The full update can be accessed here.

NPA’s MSO role

The NPA holds the role of Medication Safety officer (MSO) for all independent community pharmacies in England with fewer than 50 branches. The NPA’s MSO role was established when the Medicines and Healthcare product Regulatory Agency (MHRA) Stage Three: Directive Improving medication error incident reporting and learning alert (NHS/PSA/D/2014/005) was issued in March 2014, and has continued since.

If you operate an independent community pharmacy, and there are fewer than 50 branches in your pharmacy chain, then the NPA is your MSO. Jasmine Shah, NPA Head of Advice and Support Services, currently holds the role of MSO at the NPA. As part of this role, we are working together with the wider pharmacy sector on the patient safety agenda, and in particular we look forward to playing our full part in the work of the sector-wide Patient Safety Group.

New style report

This MSO report improves upon the previous publications and covers current hot topics in patient safety including the Pharmacy Quality Scheme (PQS), a focus on insulin and valproate, isotretinoin, sepsis, supplying medicines online, and the introduction of Real Time Exemption Checking (RTEC).

Technology has been introduced as a contributing factor in this report. There is growing awareness of errors due to technology, e.g. selection of the wrong item on alphabetical drop down lists both when prescribing and dispensing. When reporting incidents which arise as a result of technology it is important to mention ‘technology’ as a contributing factor in the incident.

Furthermore, this report discusses the role of the MSO; including the NPA’s MSO role, our work with the Community Pharmacy Patient Safety Group (PSG) and what the PSG’s role is in supporting patient safety. There is also an analysis/summary of the most common patient safety incidents reported to the NPA during the quarter.

Yellow card reporting

The Yellow Card Scheme is an essential tool that the MHRA uses to monitor the safety of medicines, medical devices and herbal or complimentary medicines. It is crucial to report problems with these products in order to improve patient safety by identifying issues such as side effects, as well as defective and counterfeit medicines or medical devices.

Analysis of reported incidents

Overall, there was a 25% increase in the total number of patient safety incidents reported in Q3 of 2019 compared to Quarter 2 (Q2) of 2019.

  • Of the incidents reported during Q3, 92% occurred in the pharmacy.
  • Prescribing errors accounted for 5% of errors reported – this is a 3% increase from Q2.

It is very important that prescribing errors are identified and reported. Historically, prescribing errors are underreported. This is because pharmacy teams usually contact the GP practice directly and resolve any prescribing issues (e.g. penicillin prescribed to a patient allergic to penicillin) by asking for a new prescription for a different drug to be issued. Following the resolution of the interventions made, such incidents are usually not recorded or recognised as prescribing errors. It is therefore very important that such errors are recognised and reported as prescribing errors. This type of reporting helps to identify the valuable role that community pharmacy teams play every day to prevent harm to patients.

Medication error categories and incidents reported during Q3 of 2019

  • The main categories of error reported were those involving medication errors such as wrong strength (26.2%), drug (25%) or formulation (11.5%).
  • There has been a notable number of ‘wrong drug/medicine’ and ‘wrong formulation’ incidents reported during this quarter involving insulins. ‘Wrong formulation’ incidents were mainly due to pre-filled pens and cartridges being mixed up. The full report includes a focus on insulin and suggested actions for pharmacy teams to prevent/reduce these types of errors.
  • Mismatching between a patient and medicine or mismatching patients accounted for 2.8% of the errors reported. This is a 5.7% decrease from Q2.

Degree of harm

The degree of harm caused to patients reported as ‘none’ (56%) and ‘near miss’ (30%) continues to make up the majority of reports.

Quality of reporting

The data reported over Q3 highlighted both good and poor reporting quality. In a couple of reports, harm was reported as ‘death’ or ‘severe’. Unfortunately due to the extremely poor quality of the reporting and lack of detail, further analysis could not be undertaken. Therefore, it is not possible to determine whether this level of harm actually occurred or not. It is vital that all incident reports are completed with sufficient detail to allow for meaningful analysis.

NPA patient safety resources

The full range of the NPA patient safety resources can be accessed here.

Contact 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:

Tel: 01727 891800 (9am-6pm Mon-Fri, 9am to 1pm Sat)

Email: (anytime)


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.

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