The purpose of reporting is to learn from mistakes, even those that cause no harm, in order to shape policy and identify training needs for the future.

For instance, consider the first scenario – ‘formulation mismatch’. If the manufacturer of the prednisolone tablets reviewed all of the incidents that involved their product so they could change their packaging designs, they may recognise the importance of indicating more clearly which products were enteric coated and which were not.

The RPS has identified the value of learning from near misses and created the ‘Near miss errors: quick reference guide’.

Many community pharmacy organisations and NHS trusts use their own in-house reporting schemes to track incidents. This information allows the organisation to identify trends and review systems.

For example, as in the first scenario, errors arise due to medicines with similar names and packaging. If medicines of the same type but different strengths are stored together, this can add to the risk. Collating information relating to incidents, such as the dispensing of a medicine of the incorrect strength, helps guide policies in order to prevent similar mistakes from happening.

Useful resources

• Information about when to report an adverse event can be found via HSE
• RPS Near miss errors: quick reference guide: (note that the terminology used by the RPS differs from that used by the NRLS)