Incident reports are used in a variety of ways to help identify and address safety risks. Although you may not always receive formal feedback on an individual incident you report, you can be assured that by feeding into the national system you are making a difference to the bigger picture of patient safety.

The MSOs meet every other month to share their learning and recommended practice changes from serious or regular patient safety incidents. Details of serious incidents and actions taken within community pharmacy are also shared with a national network of MSOs from across the health system through regular webinars. 

Incident reports are also used by the NHS national patient safety alert response panel, which determines when an NHS-wide alert should be issued relating to a safety risk. The panel recently issued alerts as a result of serious incidents relating to the risks of extracting insulin from pen devices and the risks of valproate medicines for girls and women of childbearing age. 

The MSOs also share incident trends and aggregated data with the Medicines and Healthcare products Regulatory Agency (MHRA) at regular meetings. This can be particularly valuable should any packaging changes be recommended to mitigate the risk of selection errors. A recent change was made to the packaging for chloramphenicol ear drops to reduce the likelihood of them being selected instead of chloramphenicol eye drops.

Reflective exercise

Think about a patient safety incident that recently occurred in your pharmacy:

• Was it reported? 
• Are your procedures for reporting incidents clear? 
• Was adequate time taken to reflect on what the contributory factors were?
• What actions were taken to mitigate the risk of the same (or a similar) incident occurring again?