Community pharmacy Incident Reporting:

We strongly advise all community pharmacy teams to ensure compliance with NHS/clinical governance and GPhC requirements. Ensure that all staff, including temporary and agency staff:

  • Have a clear understanding of what to do when an incident occurs in the pharmacy
  • Are able to risk assess the situation
  • Follow their dealing with incidents/or dealing with CD incidents SOP
  • Report incidents promptly through the incident reporting platform used by pharmacy
  • Complete a root cause analysis
  • Share learnings from the incident and implement any actions required

The Professional duty of candour
The General Pharmaceutical Council (GPhC) and the Pharmaceutical Society of Northern Ireland (PSNI) have previously issued a joint statement with other regulators about the professional duty of candour and the importance of being open and honest with patients when something goes wrong with their treatment or care which causes or has the potential to cause harm or distress. Access NPA update here

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.

Community Pharmacy Patient Safety Group
The community pharmacy MSOs are united in their commitment to advancing patient safety culture and practice across community pharmacy. In February 2015, with the facilitation support of Pharmacy Voice, the MSOs established a self-funded Patient Safety Group (PSG) to regularly meet and openly share and learn from each other, as well as from other safety conscious industries, consider how this learning could be applied across the pharmacy network, then work together to create the opportunities to do so. The NPA is a member of the PSG. Read more about the PSG and the Group’s work priorities here. For more information on the issues discussed at PSG meetings, please find the updates here.

Safety culture survey from Community Pharmacy Patient Safety Group

The Community Pharmacy Patient Safety Group (CPPSG) has launched a survey to gather views and to better understand the culture of reporting patient safety incidents within community pharmacy. As with previously run surveys, all members of the community pharmacy team are encouraged to participate. The views are collected anonymously and the survey can be accessed here:

The survey will explore:

  • The culture around safety reporting
  • Enablers and barriers to reporting
  • The clarity of reporting processes and the confidence of colleagues in reporting
  • Whether attitudes to safety reporting have changed.

For further information, visit the CPPSG website:

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 NPA Incident Reporting Platform (IRP): updated user-friendly platform will help you complete incident reporting effectively and in a methodological order.


  • National Patient Safety Incident Reporting Policy (Welsh Government, May 2021) .
  • The NHS Wales Delivery Unit is leading a collaborative process.
  •  Further information and forms is available on NHS Wales Delivery Unit


Northern Ireland:

NPA guidance





An error in the BNF for Children (BNFC) has been identified where the Dose Equivalence statement for valganciclovir in the BNF for adults was also inadvertently included in the BNFC. This error has now been removed on digital platforms of the BNFC and will be corrected for the future print edition of the BNFC 2021-22. Further information can be found here:


Patient safety news

Access important patient safety news

MHRA monthly Drug Safety Update

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

NPA page for drug alerts medicines recalls and company led drug alerts and recalls

Medication Safety Update (MSO) reports England

Medication Safety quarterly updates presenting our analysis of patient safety incidents reported

Medication Safety Update (MSO) reports Scotland

Bi annual medication safety updates presenting our analysis of patient safety incidents reported


The high risks associated with valproate exposure during pregnancy remains a high priority patient safety concern.

Community Pharmacy Patient Safety Group (CPPSG)

The NPA is a member of the 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.

Pharmacy Quality Scheme (PQS) resources 2020/21 - England

The NPA have worked with the CPPSG to develop resources that assist contractors to complete some of the patient safety components of the 2020/2021 (PQS).