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Patient Safety

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Patient Safety

During 2017 there was an increase of more than 45% (compared to 2016) in the number of Patient Safety Incident reports submitted by community pharmacies in England through the NPA’s patient safety incident reporting tool.

Under the quality payments scheme patient safety reporting criterion, pharmacy contractors are required to demonstrate evidence of sharing learning nationally; reporting your patient safety incidents through the NPA’s reporting tool allows us to collate learnings and share them nationally which supports you in meeting the ‘sharing nationally’ requirement. It also allows us to ensure that the right professional support is available for you. In addition, the NPA also launched the Patient Safety Incident Report form for NPA members in Scotland which is seeing increasing usage to report incidents.

The main types of patient safety incidents identified during 2017 include:

  • Issues with delivering medicines (10%)
  • Errors involving fridge lines (6%), particularly related to selectionof insulin products
  • Incorrect dispensing of medicines in a monitored dosage system (MDS) (6%), including missing one of the prescribed medicines leading to the patient experiencing withdrawal effects.

The NPA has produced a number of resources that can be used to reduce issues with the delivery of medicines including Pro Delivery Manager, the Delivering Medicines Safely & Effectively course for members of staff collecting prescriptions or delivering medicines and an updated Delivering Pharmacy Items SOP.

In addition, the NPA Pharmacy team has produced a range of Patient Safety resources to support pharmacy teams in increasing patient safety and reducing incidents, such as the insulin and inhaler identification checker, and MDS guidance. Also, due to the ongoing concerns surrounding valproate prescribing in women of childbearing potential, a valproate dispensing checklist has been produced to assist pharmacists when dealing with valproate prescriptions.

The NPA’s Medication Safety Officer (MSO) and Chief Pharmacist, Leyla Hannbeck, is urging pharmacy teams in England and Scotland to continue to report all patient safety incidents through the NPA’s reporting tool.


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