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Community pharmacy Incident Reporting

Pharmacy teams must report incidents, whether they result in harm or not. The NPA patient safety reporting form is quick and convenient to use. Before submitting, the form can be printed, or emailed, to be kept in-line with professional standards.

We strongly advise all community pharmacy teams to ensure compliance with NHS/clinical governance and GPhC/PSNI 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 pharmacy SOP with dealing with incidents
  • 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.

Pharmacists and pharmacy technicians must:

  • Inform the patient (or, where appropriate, the patient’s carer/representative) when something has gone wrong
  • Apologise to the patient (or, where appropriate, the patient’s carer/representative)
  • Rectify the error or offer an appropriate remedy/ support to put matters right (if possible)
  • Explain fully to the patient (or, where appropriate, the patient’s carer/representative) the short and long term effects of what has happened

The joint statement also states:
Healthcare professionals must also be open and honest with their colleagues, employers and relevant organisations, and take part in reviews and investigations when requested. Health and care professionals must also be open and honest with their regulators, raising concerns where appropriate. They must support and encourage each other to be open and honest and not stop someone from raising concerns.

 

Report an incident:

 

England
NPA Incident Reporting Platform

Report an incident

 

Northern Ireland
Incident Reporting Platform

Report an incident

Scotland
NPA Incident Reporting Platform

Report an incident

Wales
Incident Reporting Platform

Report an incident

 

England:

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

Contact the NPA MSO

NPA members

Independent community pharmacies in England, who are NPA members, can contact the NPA MSO, Jasmine Shah (Head of Advice and Support Services), through the Pharmacy Services Team at the NPA for further information, advice and/or support on any patient safety or pharmacy topic/matter by:

Non-members

Independent community pharmacies in England with fewer than 50 branches who are currently not members of the NPA can contact the NPA MSO by:

  • Email topharmacyservices@npa.co.uk
  • Please include your pharmacy name, ODS code, name of the owner/superintendent pharmacist and their telephone/mobile number, pharmacy’s NHSmail email address
  • State ‘Non-member MSO query’ in the subject field
Medication Safety Update (MSO) reports England

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

Access reports here

Community Pharmacy Patient Safety Group

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

Read more about the CPPSG’s work and access guidance here

Pharmacy Quality Scheme resources 2021/22

Access NPA PQS hub

Access CPPSG resources

Scotland:

NPA Incident Reporting Platform Scotland

Report an incident

Medication Safety Update reports Scotland

Medication safety updates presenting our analysis of patient safety incidents reported

Access reports here

Scottish Patient Safety Programme

Access  here

Duty of Candour (Scotland) – Annual Report Template

Access information here

 

Wales:

Patient Safety Wales

The NHS Wales Delivery Unit supports organisations in NHS Wales in improving safety and quality, developing safer environments and reducing avoidable harm.

Access here

National Patient Safety Incident Reporting Policy (Welsh Government, May 2021)

The national incident reporting in NHS Wales has changed from June 2021.

Access further information and forms here

Welsh Government

Monthly Patient safety data

Access here

Northern Ireland:

Patient Safety Incident Reporting tool

Access here

HSC Medicines Governance NI

Annoymous Reporting of adverse incidents by Community Pharmacy Services

Access here

Department of Health

Transforming medication safety in Northern Ireland

Access guidance here

 

NPA SOPs

NPA Patient Safety Guidance

NPA COVID-19

NPA COVID-19 vaccination page

NPA Services and Support hub page

MHRA Yellow card reporting

The MHRA dedicated site for reporting suspected problem or incidence to medicines and medical devices.

MHRA COVID-19 Yellow Card reporting

The MHRA dedicated site for healthcare professionals, patients and carers are asked to report all suspected side effects to medicines or medical device adverse incidents related to COVID-19 treatment, including COVID-19 vaccines.

Learn from patient safety events (LFPSE) service (ENGLAND)

NHS England Never Events

The World Health Organisation (WHO) global patient safety challenge

Community Pharmacy Patient Safety Group