Data gathered by the MSOs in January 2017 found that the number of reported patient safety incidents per 10,000 items dispensed in community pharmacy in 2016 ranged from zero to 1.90, which gives an average of 1.05 per 10,000 items. 

There is no 'correct' or 'safe' number of patient safety incidents. A 'low' reporting rate should not be interpreted to mean that a pharmacy is safe, as it may actually represent under-reporting. Similarly, a 'high' reporting rate should not be interpreted to mean a pharmacy is unsafe, but may actually indicate a culture of greater openness and a commitment to patient safety improvement. 

Pharmacy teams should always follow their company SOPs for reporting incidents, but the MSOs have developed some general best practice recommendations, including:

• All patient safety incidents should initially be handled at pharmacy level, including discussing the incident with the individuals involved and the immediate pharmacy team 
• Details of the 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 and what impact it had on the patient
• Each report should identify contributing factors and actions planned to prevent the incident from happening again
• Each report should categorise the actual degree of harm caused to the patient as a direct result of the patient safety incident.

The MSOs have also worked with NHS Improvement, NHS England and PSNC to create templates for recording the learning and improvement actions that have been taken. These reports are designed to support community pharmacies achieve the quality criteria set out in the 2017/18 Community Pharmacy Contractual Framework. Further information is available in NHS England's Quality Criteria Guidance and on the PSNC website.