Scotland patient safety incident report: November 2016 – January 2017

03 Feb 2017

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

Dear Superintendent,

I am pleased to publish my first Scotland patient safety incident report.  This is based on the near miss and error reports received from members in Scotland using the NPA online reporting tool, and covers the reports received in the first three months since its launch.  The report includes a summary of the dispensing errors reported to the NPA during the three months and 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 to keep as a pharmacy record of the incident, and patient details can be added.

All pharmacies should have robust procedures in place for recording all incidents and near misses, and for reporting incidents.  Pharmacies regisitered 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.

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 Services team on 01727 891800 or email at:

Kind regards,

Leyla Hannbeck MSc, MRPharmS
Chief Pharmacist