Scotland patient safety incident report (May 2017 – July 2017) including top tips for error minimisation

31 Aug 2017

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

Dear Superintendent,

I am pleased to publish the third Scotland patient safety incident report.  This is based on the near miss and error reports received from NPA members in Scotland using the NPA online reporting tool, and cover the reports received from May to July.  The report includes a summary of the dispensing near miss and errors reported to the NPA from Scottish members and provides 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 convenient format. The Incident Report form is submitted to the NPA, after completion, forms can be printed off or emailed to the pharmacy/ Superintendent Pharmacist/relevant staff member to keep as a pharmacy record of the incident. Patient details can be added after submission.

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 dispensing 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” which 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 Scotland patient safety incident report should help you identify potential changes to your pharmacy practice and support pharmacy staff to improve patient safety.

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

Kind regards,

Leyla Hannbeck MSc, MRPharmS, MBA, MA
Chief Pharmacist