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Scotland patient safety incident report: August 2017 to October 2017

01 Dec 2017

Superintendent update providing the fourth NPA Scotland patient safety incident report, including top tips for error minimisation

Dear Superintendent,


I am pleased to publish the fourth Scottish patient safety incident report. This is based on the incident reports received from NPA members in Scotland using the NPA online reporting tool from August to October 2017.  The report includes a summary of the dispensing near miss and errors reported to the NPA from Scottish members, and provide action points to help minimise the number of errors and improve patient safety.


The online reporting tool enables pharmacists and pharmacy staff to report near-misses and errors in an anonymous, systematic and quick use format. The Incident Report form is submitted to the NPA without patient or staff identifiers.  After completion, forms can be printed off or emailed to the pharmacy or pharmacy superintendent to keep as a pharmacy record of the incident, where patient details can be added. Records can be kept for auditing purposes.


The Scotland Patient Safety Incident Report can be used as a tool to facilitate patient safety quality improvement discussions with pharmacy teams looking at their own pharmacy environments. Both the Scottish Patient Safety Incident Report and the English Medicine Safety Officer Report provide valuable insight into developing procedures that can minimise near misses, dispensing errors and prescribing errors.


All pharmacies should have robust procedures in place for recording all incidents and near misses, and for reporting incidents.  Pharmacies registered with the General Pharmaceutical Council (GPhC) have to meet the GPhC “Standards for registered pharmacies, September 2012”.  This includes:
•   Standard 1.1 – “The risks associated with providing pharmacy services are identified and managed
•   Standard 1.2 – “The safety and quality of pharmacy services are reviewed and monitored


GPhC inspectors will expect to see evidence that pharmacies are complying with these standards, including having standard operating procedures (SOPs) for dealing with patient safety incidents, and copies of incident reports and near miss logs.


Recording the discussion of this report and any identified actions can provide evidence that you are supporting a culture of quality improvement within your pharmacy for the benefit of patient safety.

My Scottish patient safety incident report should help you identify potential changes to your pharmacy practice and support pharmacy staff to improve patient safety.


As you may be aware the NPA has developed a new portfolio of SOPs designed to ensure the safe and effective running of the pharmacy. Each SOP contains patient safety elements to support in the prevention of patient safety incidents and potential patient harm. Please remember that the SOPs are to be used in conjunction with the two supporting documents:

  1. Delegation of responsibilities
  2. Pharmacy team declaration


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


Kind regards,

Leyla Hannbeck MSc, MRPharmS, MBA
Chief Pharmacist