Scotland Patient Safety Incident Report (March to May 2018)

17 Aug 2018

Superintendent update on the NPA Scotland patient safety incident report (March-May 2018)

Dear Superintendent,


I attach my Scotland NPA Patient safety incident report March to May 2018, which includes a summary of the most common dispensing errors reported to the NPA during this period from Scottish NPA members, along with top tips for minimising patient safety incidents.

 Near miss or error?

The report highlights that there are some discrepancies with understanding the differences between “near miss” and “error”. A “near miss” is generally defined to be a mistake that is rectified before the medicine is provided to the patient, and an “error” occurs once the patient or carer has received the medicine.

Common Factors

  • The most common error reported in this quarter was the “wrong drug” supplied, accounting for nearly a third of all errors.
  • The three main contributing factors, which continue to account for errors, are “communication”, “task” and “work and environment” factors.
  • Majority of the errors (seven out of ten reports) were identified by the patient or carer.
  • A quarter of errors resulted in a breach of compliance with the General Data Protection Regulation (GDPR).
  • A fifth of errors were classed as “wrong dose or strength” with one eighth being “wrong quantity”.


Errors involving mismatching patients and medication

Reported errors frequently occurred due to simultaneously receiving and dispensing prescriptions for different family members often with the same surname. Examples of these types of errors occurred in a number of ways including:

  • Two patients arriving together to wait for prescriptions which they hand in together.
  • Two patients arriving together to receive their supervised doses of medicine.
  • A family’s repeat prescriptions folded together as part of the surgery prescription bundles received.
  • The wrong patient repeat ordering slip supplied in the prescription bag.

For top tips on how to lower the risk of these types of errors, please see our Scotland NPA Patient safety incident report March to May 2018 for further information.

 Errors involving professional-to-professional communication

  • Frequent staff turnover in GP surgeries and care agencies, can result in a lack of understanding of how significant to patient care pharmacy communications are, which in turn can lead to dispensing errors being made.
  • Have a protocol in place to ensure pharmacy communications are consistent in process, and share these protocols where appropriate with other professionals you may require to contact.

 NPA support
The NPA has published a suite of patient safety SOPs to assist you in ensuring you have robust processes in your pharmacy. These and other patient safety resources can be freely accessed from our patient safety page on the NPA website. The Medicine Safety Officer report on English error reports submitted to the NPA is also a useful reference source to identify ways to improve patient safety in your pharmacy.

For further information, advice and/or support on any patient safety or pharmacy topic/mater, please contact the NPA Pharmacy Services team on 01727 891800 or email at:

Kind regards,


Leyla Hannbeck MSc, MRPharmS, MBA
Director of Pharmacy