Archived on 30 November 2015 – this content has expired.

Patient safety incidents: MSO report (March – June 2015)

01 Jul 2015

Superintendent update providing a Quarter 2 report on the findings from the NPA Patient Safety Incident Report forms received by the NPA.

This report is for Quarter 2, which covers March to June 2015.  This is the first report.

Key Statistics

The percentages set out below relate to the number of reports which gave a particular answer to a question, expressed as a percentage of the number of answers received for that question. Not all reports answered all questions.

  • 1) Stage of the medication process when the actual or potential error occurred:
    • 76% — ‘Preparation of medicines in all locations/dispensing in a pharmacy’
  • 2) Type of medication incident reported:
  • 30% —‘ Wrong drug/medicine’
  • 25% — ‘Wrong/unclear dose or strength’
  • 3) Important factors in the medication incident:
    • 64% — ‘Medicines with a similar looking or sounding name’
    • 14% — ‘Poor labelling and packaging from a commercial manufacturer’
  • 4) Contributing factors in the medication incident:
  • 44% — ‘Work and environment factors (e.g. poor/excess administration, physical environment, workload and hours of work, time pressures)’
  • Examples:
    • “busy, main dispenser off work”
    • “self-dispensing and checking due to workload and insufficient numbers of staff”
  • 5) Severity of actual harm incurred by patient:

A ‘near miss’ is where the incident was resolved without involving the patient — for example, where the final check identified the problem and the incorrect medication never reached the patient; whereas an ‘error’ is when an incorrect medication actually reaches the patient.  Errors are classified as ‘no harm’, ‘low harm’, ‘moderate harm’, ‘severe harm’ and ‘death’.

  • 29% — Near miss
  • 44% — No harm
  • 12% — Low harm
  • 15% — Moderate harm


Some of the medicines with similar names involved in the incidents

  • omeprazole/olanzapine
  • pravastatin/pantoprazole
  • Seretide/Serevent
    • NovoRapid/NovoMix

Minimising risk / general action points

  • Physically separate products with similar names on dispensary shelves
  • Put warning stickers on shelves reminding staff to take care when selecting stock — for example, different strengths of methotrexate
  • For insulins, show box to patient before handing over
  • Training — to ensure pharmacy staff are aware of different insulin formulations, for example
  • Share details of common errors and near misses with pharmacy team
  • Consider staffing levels across the day – are there enough members of staff at the busiest times?
  • Review Standard Operating Procedures (SOPs) – SOPs for supplying insulin and other specific   medicines are available on the Patient Safety / Medication Safety Officer page of the NPA website. 

Using the NPA Patient Safety Incident Report form

Pharmacies which use the NPA Patient Safety Incident Report form do not need to submit reports to NHS England or the National Reporting and Learning System (NRLS) as we do this on your behalf.  

Information is sent anonymously, so that NHS England and NRLS cannot identify the pharmacy, patient or any members of staff involved in the incident. Pharmacies can print out a copy of their reports once completed and add in patient details by hand. Keeping these copies can be useful both to identify common errors that the pharmacy is making and to take action to prevent them. In addition, it can help the pharmacy to meet the record-keeping standards for principle 1 of the General Pharmaceutical Council (GPhC) inspection model.

The NPA recommends that all independent community pharmacies in England with fewer than fifty branches use the NPA form to report incidents. As your MSO, I need to know about the incidents that are happening, even if you are reporting incidents using an alternative form.  Additionally, the greater the number of reports we receive, the more we will be able to identify common errors and factors contributing to them.  We can share this information with you and use it to identify ways to minimise the chances of the errors recurring. 

Indemnity insurance
Some pharmacists working at NPA member pharmacies may have their own separate indemnity insurance in place. I would like to remind you that whenever an error or incident comes to light, pharmacists who have their own indemnity insurance should notify their insurer immediately.  Failure to do this could result in them having no indemnity cover. 

For further information on any of the above, please contact the NPA Pharmacy Services Team on 01727 891 800 or email .