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Patient Safety

  • Wales
  • England
  • Scotland
  • Northern Ireland

In September 2014, NHS England and the Medicines and Healthcare products Regulatory Agency (MHRA) recommended that all large community pharmacy organisations identify a named Medication Safety Officer (MSO) to review incidents and oversee safety improvements within their organisation.

Research evidence shows that medication errors and adverse drug reactions are common at all stages of the medicine use process and are associated with a high cost in terms of patient outcomes as well as financial consequences due to additional treatment or litigation.

Community pharmacy organisations with more than 50 branches will have an appointed MSO. They are usually the Superintendent Pharmacist or a senior member of their team. Numark gained MSO status to support any of their members with fewer than 50 branches. The National Pharmacy Association (NPA) also has an appointed MSO for pharmacies with less than 50 branches. This ensures that the whole community sector is covered.

The role of the MSO includes:

  • Promoting the safe use of medicines
  • Supporting pharmacy teams in improving patient safety
  • Improving reporting and sharing learnings from patient safety incidents submitted

As the MSO for our members we intend to keep you up to date with any Patient Safety Alerts, Medicine Recalls and Drug Safety Alerts when they are issued by the MHRA. We will also be providing a regular safety report analysing patient safety incidents reported using the Pharmapod incident reporting platform, looking at trends in the most commonly reported incidents and offering advice to help minimise identified risks in the future.

The Pharmapod incident reporting system is cloud based and designed to work on either a tablet or desktop.

Sign up to Pharmapod

Community Pharmacy Patient Safety Group

The Community Pharmacy Patient Safety Group (CP PSG) was set up as a network of MSOs operating in community pharmacy on which Numark takes an active role. We seek to collaborate on issues of patient safety to raise awareness of the importance of reporting, learning and sharing and to create a consistency across community pharmacy.

They have developed a set of patient safety incident reporting principles using the Report, Learn, Share, Act, Review (RLSAR) wheel. This provides a simple framework which pharmacy teams can use to structure their actions when reporting a patient safety incident.

RLSAR principles

  • REPORT all errors and near misses
  • LEARN by identifying and investigating the causes of errors
  • SHARE by discussing within the team
  • ACT by making changes to practice
  • REVIEW the changes made to practice

Patient Safety Resources

Numark have a suite of SOPs that can be used to ensure best practices involving patient safety are followed by the whole of the pharmacy team.

Dealing with Near Misses and Errors SOP

Dealing with Near Misses Errors Flowchart 

Patient Safety Incident follow up

SOPs for dispensing of high risk medicines including: