Scotland patient safety incident report (November 2017 – January 2018) and a summary of patient safety in 2017

08 Feb 2018

Superintendent update on the NPA Scotland patient safety incident report (November 2017 – January 2018)

Dear Superintendent,

I am pleased to publish the latest Scotland patient safety incident report. This report is based on near misses and patient safety incidents reported to the NPA via the online Patient Safety Incident report form (Scotland) between November 2017 and January 2018.

The online report form enables pharmacy team’s to report near-misses and patient safety incidents in an anonymous, systematic and efficient format. After completion, forms can be printed off or emailed to the pharmacy or superintendent to keep as a record of the incident; records can be kept for auditing purposes.

The report also includes top tips and guidance to help reduce patient safety incidents involving Controlled Drug (CDs) and best practice for dispensing and recording CDs, as well as conducting CD audit checks. The report can be used as a tool to facilitate patient safety discussions within the pharmacy team, looking at their own pharmacy environment and areas to improve. The report offers a valuable insight into developing procedures that can minimise near misses, dispensing errors and prescribing errors.

Top patient safety topics of Quarter 4 2017
During Quarter 4 of 2017, I raised a number of important patient safety topics, within my superintendent updates, tackling a range of issues. Patient safety incidents associated with dispensing opioid medicines is a recurring and prominent issue, as highlighted by the National Reporting and Learning System (NRLS) alert released in 2008. The NPA developed a patient safety resource for dispensing opioids, including top tips, in order to reduce the number of opioid related patient safety incidents.

Valproate and the associated risks of birth defects due to in-utero exposure remain a patient safety priority with the Medicines and Healthcare products Regulatory Authority (MHRA) – the NPA developed a valproate dispensing checklist to assist pharmacy teams with the patient safety aspects when dispensing valproate for women who are pregnant or of childbearing potential.

Finally, I raised concerns around antibiotic prescribing errors, following a number of reports received. To assist pharmacy teams to remain vigilant of antibiotic prescribing errors and provide guidance on how to manage such errors, there is a suggested checklist to follow when performing a clinical check, along with guidance on use of appropriate clinical resources and raising concerns with prescribers.

Eye products identification checker
The NPA has seen an increase in the number of errors involving dispensing of combination products against generic and branded prescriptions – products with two or more active ingredients, in particular eye products. As a result, the NPA has developed an ‘Eye products identification checker’ resource, which is designed to support pharmacy teams in dispensing and accuracy-checking generically written prescriptions for eye products.

The resource is comprised of two parts; part one – licensed eye products and part two – eye devices. The resource also includes the drug class, generic name/active ingredients and strength, brand name (where applicable), formulation, preservative content and shelf life after opening.

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

Kind regards,

Leyla Hannbeck MSc, MRPharmS, MBA
Chief Pharmacist