Reporting incidents as soon as they are identified may be critical to the immediate safety of the patient concerned. It also allows for a full investigation to start in an appropriate time frame, ensuring that details are available and lessons are learned as soon as possible. Each pharmacy will have its own incident management standard operating procedure (SOP) and should conduct an internal review to understand the underlying causes or events that led to the incident, as well as any other contributory factors. 

In addition to managing the incident at a local level, reporting what happened and what action was taken in the pharmacy to prevent a similar incident happening again raises awareness of potential risks and allows other pharmacy teams to learn from something that has gone wrong. Teams can then reflect on their own practice to consider whether any changes should be made to minimise risks to patients.  

Key facts

• Community pharmacies should have robust but simple systems in place for staff to use when an incident occurs
• Details of every incident should be recorded and reported as soon as possible after it takes place
• Reports should be factual and include enough detail for someone who was not present to understand what happened 
• There is no ‘correct’ or ‘safe’ number of patient safety incidents
• Incident reporting rates in community pharmacy range from zero to 1.90 incidents per 10,000 items dispensed
• The ‘Report, Learn, Share, Act, Review’ wheel provides a simple framework for identifying and reporting patient safety incidents 
• The value of reporting patient safety incidents is not always seen immediately, but this does not mean that these reports are not used at local and national levels to improve practice.