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.
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: https://pharmacysafety.org/
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
MHRA Drug Safety Update
World Antibiotic Awareness Week 18-24 November 2020
MHRA Drug Safety Update
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
MHRA Drug Safety update
New measures for methotrexate
MHRA stimulant laxatives drug safety update
NPA resources – laxatives
MHRA guidance on using emollient skin creams safely
Direct-acting oral anticoagulants (DOACs) —increased bleeding risk – MHRA Drug Safety Update
MHRA drug safety update on reducing risk of meningioma with cyproterone acetate
Valproate Pregnancy Prevention Programme: temporary guidance issued by MHRA during COVID-19 pandemic
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.
CAS Alert: Novel Coronavirus – 13 March 2020 – Community Swabbing services
Coronavirus disease 2019 – latest advice and guidance
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
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
Supply disruption for all oral preparations of generic ranitidine
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).
To support the risk management domain access the following resources: https://pharmacysafety.org/pharmacy-quality-scheme-2020-2021/
- Guidance for completing risk reviews
- Risk review templates
- Worked examples of the Risk Review
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)