Community pharmacy Incident Reporting:

England – Report an incident

Northern Ireland – Report an incident

Scotland – Report an incident

Wales – Report an incident


In September 2014, NHS England (now NHS England & NHS Improvement), and the MHRA, issued a Stage Three Directive recommending all large community pharmacy organisations (as well as NHS Trusts, homecare companies and independent providers) to identify a named Medication Safety Officer (MSO) to review medication incidents and oversee safety improvement. Most of the MSOs in community pharmacy organisations are the Superintendent Pharmacist, or a senior member of their team, and are also the point of contact for safety for their pharmacy teams located outside of England.

The National Pharmacy Association (NPA) also appointed an MSO to fulfil this role for community pharmacies with fewer than 50 branches. Jasmine Shah (Head of Advice & Support Services, NPA) has been appointed to this role currently.

MSO responsibilities for supporting pharmacy businesses and superintendents include:

  • Promoting medicines safe use
  • Implementing local and national medication safety initiatives
  • Improving patient safety on a day-to-day basis
  • Submitting incident error reports
  • Improving reporting and learning from patient safety incidents
  • Responding to requests from the Patient Safety Domain in NHS England and Medicines Healthcare product Regulatory Agency (MHRA) for further information about medication error incidents

The Incident Reporting Platform (IRP): updated user-friendly platform will help you complete incident reporting effectively and in a methodological order – IRP guidance coming soon!

Quality Payments Scheme (QPS) : part of the QPS is the requirement to develop a risk review – a template and example are available for you to use.


The Medication Safety Service is currently being piloted in Scotland.

Read our guidance for completing the Patient Safety Incident Report form

Read our second patient safety report in 2020 for Scottish members.

Northern Ireland:

A new Patient Safety Incident Reporting tool is now available. Members in Northern Ireland can continue to anonymously report patient incidents to HSCB.

Guidance on completing the new online reporting can be found here.

Community Pharmacy Patient Safety Group

The NPA is a member of the Community Pharmacy Patient Safety Group (CPPSG).

The CPPSG is made up of 19 like-minded people Medication Safety officers (MSOs) with a passion for patient safety. We seek to collaborate and find practical solutions to safety challenges, raise awareness of the importance of reporting, learning and sharing, champion the development of a safety culture and create consistency across community pharmacy.

Access the CPPSG website for further information and resources:

Patient safety NPA resources, updates and reports:

***Packaging changes for some buprenorphine patches***
Butec and Transtec (buprenorphine) patches will now be supplied in child-resistant sachets, which means the sealed sachets must now be cut with scissors rather than being torn open as previously. The Patient Information Leaflet, and markings on the sachet have been updated to indicate the change.

  • Pharmacists and pharmacy teams are advised to counsel patients on this change which will be effective in all new stock bearing serialisation codes


Patient safety news 

December 2020

MHRA Drug Safety Update

November 2020

World Antibiotic Awareness Week 18-24 November 2020

MHRA Drug Safety Update

October 2020

Sanofi drug alert: Epilim gastro-resistant tablets 500mg

Patient safety considerations for OTC medicines

Supply of Priadel® modified-release tablets 200mg and 400mg

MHRA Drug Safety Update

September 2020

MHRA Drug Safety update 

New measures for methotrexate

MHRA stimulant laxatives drug safety update

NPA resources – laxatives

August 2020

MHRA guidance on using emollient skin creams safely

July 2020

Direct-acting oral anticoagulants (DOACs) —increased bleeding risk – MHRA Drug Safety Update

MHRA drug safety update on reducing risk of meningioma with cyproterone acetate

May 2020

Valproate Pregnancy Prevention Programme: temporary guidance issued by MHRA during COVID-19 pandemic

April 2020

We are aware of the publication of the proposed changes to Controlled Drugs (CD) legislation to support patient care during the current COVID-19 pandemic. It is important to note that these are proposed legislative amendments, which have not yet been enacted and are not yet in place. The NPA has produced a template letter, Controlled Drugs legislation – letter of clarification (April 2020), which can be used, if required, to inform local prescribers of the current legislative requirements.

March 2020

CAS Alert: Novel Coronavirus – 13 March 2020 – Community Swabbing services

February 2020

Coronavirus disease 2019 – latest advice and guidance

December 2019

Domperidone –change in licensed age groups and weight ranges

Opioids and tricyclic antidepressants – risk of severe interaction

Metformin diabetes medicines – MHRA Update

Superabsorbent polymer gel granule ingestion – risks of death and severe harm

Influenza season 2019/20 – antiviral prescribing

Emerade® – supply disruption alert

Supply disruption for Convulex® (valproic acid) capsules – all strengths

November 2019

Slo-phyllin® (theophylline) capsules – all strengths discontinued

Supply disruption for all formulations of generic ranitidine – update 27 November 2019

Yellow fever vaccine: Stamaril – additional robust precautions for specific patient groups

October 2019

Supply disruption for all oral preparations of generic ranitidine

September 2019

Fire hazards with Diprosone ointment and ondansetron use in pregnancy – updates from NICE

Pharmacy Quality Scheme Resources 

The cross-sector Community Pharmacy Patient Safety Group, of which the NPA is a member, have worked to develop resources that assist  contractors to complete some of the patient safety components of the 2020/2021 Pharmacy Quality Scheme (PQS).

October 2020

To support the risk management domain access the following resources:

  • Guidance for completing risk reviews
  • Risk review templates
  • Worked examples of the Risk Review

NPA Guidance


MSO quarterly updates (England)

Patient safety incident reports (Scotland)

Valproate: risk during pregnancy

The high risks associated with valproate exposure during pregnancy remains a high priority patient safety concern; alerts have been issued via: NHS Improvement (England), Patient Safety Wales (Wales), Healthcare Improvement Scotland (Scotland), Safety Quality and Standards Circulars (NI)


Drug alerts, medicines recalls and company-led drug alerts and recalls

NPA one-stop page for drug alerts, medicines recalls and company-led drug alerts and recalls