The first thing that needs to be thought about when a patient safety issue arises is how to record the incident and near-miss data. Having no incident data indicates that there is an issue with reporting and doesn’t indicate that a team is working more safely.

According to NHS Improvement, “patient safety incidents are any unintended or unexpected incident which could have, or did, lead to harm for one or more patients receiving healthcare”. There are other terms that can be used, which fall under the umbrella of patient safety, for example, medical errors, medication error or medication safety incident. The broader term of ‘patient safety’ allows consideration of the wider systems that pharmacy is involved in and not solely factors that lead to medication errors.

When it comes to reporting near miss and patient safety incidents in pharmacy, there may be an in-house reporting system in place, which could be electronic or paper-based. This will feed into the National Reporting and Learning Service (NRLS). If there is not a system in place, incidents will need to be directly reported to the NRLS. 

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

It is important that incidents are reported to the NRLS so that the whole of the NHS, including other pharmacies, are in a position to learn from past incidents and prevent future occurrences.