Why is it important to report medicine errors and NMEs? 

Professionalism and a culture of candour are vital for patient safety, and this is why it’s important that pharmacists regularly report, learn, share, act and review instances when there’s been errors or NMEs. 

The sharing and review of data from error reporting can result in improvements to patient safety and prevent similar mistakes from happening in the future.

The General Pharmaceutical Council (GPhC) requires pharmacists to “speak up when they have concerns or when things go wrong” and encourage the reporting and learning from errors. GPhC has published guidance to support on the professional duty of candour. Further information can be found in the Standards for pharmacy professionals and Guidance to support the standards for pharmacy professionals on the GPhC website.

Types of medicine errors and NMEs, possible causes and considerations 

A medicine-related error can occur at the following stages:

• Administering
• Dispensing/supplying
• Monitoring
• Prescribing
• Transcribing

The following information looks at the possible causes and what you could consider for review:

Administering 

Administration errors may include: 

• Administration of a medicine to which the person has a known allergy 
• Administration of the wrong medicine/dose/route/time
• Administration without a valid prescription 
• Inappropriate administration of ‘prn’ medicines
• Incorrect infusion rate 
• Medicine administered to the wrong person
• Medicine incorrectly prepared/reconstituted 
• Medicine omitted without a clinical rationale 
• Not following ‘warning’ advice when administering (e.g., take with or after food) 
• Person administered an out-of-date medicine
• Person administering is not competent or is not appropriately trained.

Dispensing

The table below covers the different types of NMEs which may occur during the dispensing process, the possible reasons behind them and the things you should consider when reviewing (list not exhaustive).

Type of dispensing NMEs	Possible causes (non-exhaustive)	Things to consider when reviewing (non-exhaustive)
Wrong product	– Product put away at wrong location – Product selected incorrectly – Products mixed on dispensing bench – Misread prescription (Rx) – Similar packaging – Additional product – Do the packs look similar? Should you separate? – Who puts away the products? Training issues? – More than one Rx being dispensed at a time? See also ‘misread Rx’ – Do you dispense from the Rx & not the labels? – Wrong product ordered or delivered by wholesaler? – Has the wrong product been placed in another bag?	– Do the packs look similar? Should you separate?  – Who puts away the products? Training issues?  – More than one Rx being dispensed at a time? See also ‘misread Rx’  – Do you dispense from the Rx & not the labels?  – Wrong product ordered or delivered by wholesaler?  – Has the wrong product been placed in another bag? – Are you checking the expiry dates of medicines regularly? – Does stock rotation occur? – Are you checking the expiry date when you pick the medicine off the shelf and carry out the final check? – Do the short dated products have a warning/alert sticker on them – Are there any more out of date products on the shelf? – Do you check expiry dates of products when receiving them from the wholesaler?
Out of date product	– Out of date products on shelf – Out of date product sent from supplier	– Are you checking the expiry dates of medicines regularly? – Does stock rotation occur? – Are you checking the expiry date when you pick the medicine off the shelf and carry out the final check? – Do the short dated products have a warning/alert sticker on them? – Are there any more out of date products on the shelf? – Do you check expiry dates of products when receiving them from the wholesaler?
Wrong formulation	– Inadequate prescription detail – Product selected incorrectly – Misread Rx	– See also ‘misread Rx’ – Is everyone familiar with all formulations? – Do the different formulations have similar packaging? Should they be stored separately?
Wrong/transposed/omitted label	– Incorrect transfer of information from the Rx – Misread Rx – Labelling in batches – Incorrect label stuck on the wrong product – Products mixed on dispensing bench	– Errors likely when label selected from repeats on PMR – Are products dispensed and labelled one at a time? – Is the dispensing bench clear of clutter and tidy?
Missing item	– Products mixed up on dispensing bench – Fridge line / CD / Owing – Misread Rx – Product not dispensed in a Multicompartment compliance aid (MCA), dispensed separately – Has the product been ordered or out of stock?	– Has the missing product been placed in another bag? – Consider use of dispensing basket – Warning label informing of fridge / CD line / owing outstanding – Dispense and label one product at a time – Item missed out when preparing for delivery/collection
Wrong name	– Incomplete Rx reception process – Previous person selected from PMR – Identical names – Wrong person selected from PMR – Misread Rx – Full name not provided on prescription	– Team training issues? – Distractions – Warning for all team members that two people have the same name – Enough detail on PMR to deal with similar names? – See also ‘misread Rx’
Misread prescription (Rx)	– Inadequate / ambiguous details – Hand-written prescription – Poorly performed Rx evaluation process	– Training issue – Visual impairment – Was professional evaluation performed?
Wrong quantity	– Incorrect transfer of information from Rx – Misread Rx or calculation error – Counting error during dispensing	– Have you selected label from PMR or Rx? – Can someone else check your calculation? – If using a counting machine, is it regularly calibrated and checked for accuracy? – Several pack sizes available
Wrong strength	– Product put away at wrong location – Product selected incorrectly – Products mixed on dispensing bench – Misread Rx	– Do the packs look similar? Should you separate? – Who puts away the goods? Training issue? – Are packs placed on shelf with contents identity visible? – Have you read the Rx correctly? Dispense from the Rx not the label
MCA/Monitored Dosage System	– Product in wrong compartment – Missing/omitted product – Product unsuitable for inclusion in MCA	– Is there a SOP in place for dispensing into MCA? – Is a visual description available for each product – Distractions – Using manufacturer’s info on drug stability – Using RCPharm’s available guidance – Specialist Pharmacy Service website.

Monitoring

Errors at this stage may occur when tests are not requested or performed at the required time.

Monitoring of medicines, in particular high-risk medicines (e.g. Disease-modifying antirheumatic drugs (DMARDs), lithium, warfarin and direct oral anticoagulants (DOACs) etc), should occur following national and local clinical guidance, shared care agreements and the manufacturer’s summary of product characteristics for the medicine.

It’s important to ensure required tests are performed at the correct intervals and frequency. They should also be interpreted and actioned appropriately.

Prescribing

See the following articles on causes for prescribing errors and how to avoid them:

• Pharmaceutical Journal article on The top ten prescribing errors in practice and how to avoid them – February 2019. 
• The Medical Defence Union journal article on Prescription errors – July 2016.

Transcribing

See the following pages on risks of transcribing and how to avoid them:

• SPS guidance on Risk assessing transcribing for administration – February 2022.
• RPS (now RCPharm) Professional Guidance on the Administration of Medicines in Healthcare Settings – January 2019.

Preventing medicine errors and NMEs

Here are some considerations to help prevent errors and NMEs:

• Regularly review people’s medicines to ensure they are taking the right medicines as prescribed – you may find our medication review guide helpful (to be added soon).
• Ensure medicine use is as safe as possible, safety covers all aspects of medicines usage, including unwanted effects, interactions, safe processes and systems, and effective communication between professionals –  you may find our clinical check guide helpful.
• Ensure people and their carers feel able to ask healthcare professionals when they have a query or a difficulty with their medicines.
• Ensure people and their carers feel able to discuss potential side-effects in reporting to the Medicines and Healthcare products Regulatory Agency (MHRA).
• Ensure people and their carers understand to take unused medicines to community pharmacies for safe disposal.
• Work with the pharmacy and multidisciplinary team to investigate errors, NMEs and critical incidents, using appropriate tools (e.g. significant event analysis, human factors and/or root cause analysis).
• Identify trends/patterns in medicines related errors, working with the team to develop and introduce mitigations, monitoring the impact of any changes on patient safety.
• Develop educational interventions based on evidence of the learning need through analysis of errors.
• Create a team culture that normalises and promotes learning from errors, incidents/NMEs to improve practice – see MEP section 2.5.1 for further information.
• If you are a prescriber, use our guide on independent prescribing (to be added soon) for support with prescribing safely.
• Regularly reflect on your knowledge and skills and carry out relevant learning – remember to log your learning in your MyCPD e-Portfolio.
• Review practice through clinical governance (e.g. performing regular audits) – you may find our clinical governance guide (to be added soon) helpful.
• Review people on repeat medicines – you may find our repeat prescribing toolkit (to be added soon) helpful.
• Take ownership of significant and serious problems, including resolving errors or incidents that have occurred.
• Report near misses and critical incidents, as well as medication and prescribing errors using appropriate reporting systems, whilst regularly reviewing practice to prevent recurrence.
• Use systems (decision support tools and electronic dispensing/prescribing systems) correctly to avoid potential system errors.
• Ensure the pharmacy team have access to appropriate rest breaks, both for your and your team’s welfare and patient safety – see our workforce wellbeing page.
• Ensuring physical working environments are fit for purpose.
• Ensure there are mechanisms in place for raising concerns.
• Ensure you match resources to demand and workload.
• Delegate a member of the pharmacy  team to be a medicines safety lead and sign up to safety alerts, e.g., MHRA patient safety updates and cascade actions to the team).
• Reflect on your prescribing skills regularly using our competency framework for all prescribers.

How should I deal with NMEs?

Mistakes do happen. To support clinical governance in pharmacy, regular review of NMEs and action taken can prevent similar mistakes from happening in the future. 

Use our tools below to help support clinical governance in pharmacy and to promote an open culture of recording of NMEs so that everyone in the pharmacy team can reflect and learn from them. 

Near miss error log 

This near miss error log (NMEL) can be downloaded and printed off to regularly record dispensing NMEs. 

By filling in the NMEL, you can collect sufficient information to help capture/visualise the pharmacy environment at the time of the NMEs. It can also help you regularly review and identify areas that need improving or changing.

How to complete the log

The NMEL can be used to record the following:

• Date
• Time of day – e.g., M = Morning, L = Lunch, A = Afternoon, E = Evening
• Staffing level – record number of staff:
  • Number of pharmacists = N x P
  • Number of foundation trainee pharmacists = N x FTP
  • Number of technicians = N x T
  • Number of dispensers = N x D
  • Number of healthcare assistants = N x H
• Dispensed by (optional) – you can keep this anonymous if it promotes recording of all NMEs
• Checked by (optional)
• Name and brand of medicine/device
• Type of NME (see table)
• Possible causes (see table)
• Things to consider (see table)
• Action taken
• Potential adverse event discussion (tick on completion) – e.g., possible adverse events if the error had not been picked up and reached the the patient instead.

Practical tips on using the NMEL

• Record all NMEs as and when they happen.
• Record sufficient information to help capture/visualise the pharmacy environment at the time.
• Nominate a NME lead or champion who regularly encourages everyone to record the NMEs everyday (e.g., by ensuring that locums/temporary team members are aware of where the NMEL is located and how to fill it in).
• You can use shorthand under section ‘staffing level’ (e.g., 2P + 1T + 1D + 1H = 2 pharmacists, 1 technician, 1 dispenser+ 1 healthcare assistant) .
• Under sections ‘dispensed by’ and ‘checked by’ you have the option to either record team members involved or anonymously, whichever your team believes will encourage accurate recording of all NMEs. If anonymous, ensure you’re still able identify learning needs.
• Use the table to help fill in sections such as, ‘type of near miss’, ‘possible causes’ and ‘things to consider’.
• Have a team discussion to raise awareness of potential consequences and adverse effects to the person had the error reached them and record once this has happened.
• Under the section ’actions taken’, you can record any immediate actions taken (e.g., checking if there are any more out of date products on the shelf or sending team members on their break if they are tired/at risk of making errors).
• Completed NMEL can be stored for future reference.

Near miss error reflection and improvement tool

This near miss error (NME) reflection and improvement tool can be downloaded and printed off, then used to analyse and review the information reported in the NMEL. 

It can be used to promote a continual process of learning and improvement. 

Pharmacy teams can identify trends in NMEs, discuss possible causes/contributing factors and develop an action plan to help prevent similar future NMEs. 

This action plan can be reviewed later to determine its success. 

How to complete the tool 

1. What

What went wrong? You can transfer information from the NMEL in this section. Record the facts, including:

• Types of near misses: 4xD, 3xF (4 x wrong product, 3 x wrong form)
• Time of day error occurred: 3xA, 2xE (3 x afternoon, 2 x evening)
• Staffing levels when error occurred: 1xP, 2xD (1 x pharmacist, 2 x dispensers)
• Identify trends/patterns relating to pharmacy environment: most NMEs occur at weekends/involve the wrong product/involve changes or new packaging/involve medicines with similar names/are labelling errors in the morning/involve new starters.

2. Why

Why did the NME happen? What were the causes/contributing factors? For instance:

• People – a team member called in sick, a new team member working a busy shift
• Environment – very busy time, phone ringing was distracting, pharmacy is untidy, expiry date checking of medicines incomplete, locum working at weekend with less support staff
• Education and training – new starters not trained yet
• Equipment – tablet counter broke, equipment needs recalibrating or is due for servicing.

3. React (action plan)

Address why the error occurred to prevent future errors.

• Identify possible solutions, generate ideas for improvements.
• Develop an action plan using SMART objectives. 
• Consider what needs to stop/change/improve? (e.g., provide new staff with appropriate training/schedule time to complete expiry date checking/adjust shift patterns to provide more staff for locum at weekends/Re-visit SOPs).

4. Review

Review action plan at the beginning of the next review. To ‘check in’ on ideas from proposed action plan.

• Was the action plan carried out to completion? (E.g., time allocated to date check stock)
• What was the outcome? (E.g., expiry date checking up to date since last review)
• Were the actions a success? If so, continue with changes, e.g., no NMEs involving out of date medicines since and new starter following training plan and feels supported.
• If not successful, reconsider and revise action plan in the next review.

Ask for feedback from all team members including locums. The pharmacist can then sign and date the tool to demonstrate that this has been completed.

Practical tips on using the tool

• Information collected in the NMEL can be transferred to the NME reflection and improvement tool for analysis and review.
• Designate a period of time to review the NMEs (e.g. Every 10 NMEs/weekly/ monthly).
• Input the data into the tool for analysis and review.
• All pharmacy team members to be part of/briefed on the review.
• All pharmacy team members have an opportunity to learn from NMEs and generate ideas on how to prevent future errors.
• NME % = Total number of near misses/Total number of prescriptions dispensed*100.
• Calculating the NME % for each review period can help you identify trends (e.g. weeks or months when when NME percentage is higher. Pharmacy team can then plan ahead for these anticipated periods).
• Review to be a continuous, cyclical process to promote continuous learning and improvement implementation.
• At the start of each review, consider the action plan from the previous review. Was it a success? If not, reconsider and revise the action plan in the next review.
• The pharmacist who led the review can fill in their details, sign and date.
• The remaining pharmacy team involved in the review can sign/initial and date to demonstrate their involvement in the review.
• Completed NME tools can be stored for future reference.

How should I deal with a medicine error that has reached a person?

Whether you are the person who made the error or another member of the pharmacy team, once you become aware, you need to promptly take all reasonable steps to let the person know and to make things right, unless the circumstances mean it’s not necessary or appropriate to.

Keeping records can also help to justify your decision.

Steps for dealing with errors

1. Take steps to let the person know promptly
2. Make things right (this may involve the prescriber)
3. Offer an apology
4. Let colleagues involved in the error know

Use the steps from the error reporting standards illustrated below.

RCPharm Patient safety professional standards: responding to patient safety incidents

In collaboration with the Pharmacy Forum of Northern Ireland and the Association of Pharmacy Technicians UK, we published Patient safety professional standards: responding to patient safety incidents. The standards are supplemented by an explanation of how pharmacy services protect patients, the link with patient safety, practical aspects and barriers to reporting, sharing, learning, taking action and review.

Standard 1 Reflect	Proactively and regularly reflect on existing knowledge, understanding, safety culture and systems.
Standard 2 Be open and honest	Be open, honest and responsive when a patient safety incident occurs.
Standard 3 Review	Review all patient safety incidents in a timely manner to identify an appropriate response or action,
Standard 4 Record and report	Record and report in a timely manner using the appropriate internal, local and national reporting mechanisms.
Standard 5 Act	Take relevant action in a timely manner to manage risk, strengthen, change or improve the quality of practice or systems of care.
Standard 6 Share learning	Share learning from appropriate patient safety incidents with relevant individuals and organisations to improve patient safety.
Standard 7 Evaluate	Regularly evaluate systems, interventions and changes made to practice.

Considerations:

• Do all of your pharmacy team members know who, how and what to report?
• Is reporting a team effort?
• Do you record all NMEs?
• Use Quality Improvement (QI) tools to make this process more robust and effective 
• It’s important that you have a system in place to review changes to practice – QI helps.

Further information

• Community Pharmacy Scotland Root Cause Analysis (RCA) tool
• GPhC Pharmacy team toolkit – learning from incidents June 2022

Reporting medicine errors

Learn from patient safety events (LFPSE) service is being rolled out across England, Wales and Northern Ireland. It will replace the National Reporting and Learning System (NRLS). You will need to speak to your  local safety team to find out which system you should be using.

In Scotland, Local reporting systems with a focus on quality improvement and learning are promoted. The Healthcare Improvement Scotland Adverse Events National Framework on the Healthcare Improvement Scotland website, provides useful context.

If controlled drugs (CDs) are involved, you should also  report this to your local CD accountable officer (CDAO). Here’s where you can find details of your local CDAO:

• Care Quality Commission Register of accountable officers in England.
• Healthcare Improvement Scotland Register of Controlled Drugs Accountable Officers (Scotland)
• Healthcare Inspectorate Wales Accountable Officers of Controlled Drugs.

Here’s where to report patient safety incidents across England, Scotland and Wales: 

	Registered pharmacy or GP practices	NHS hospital or NHS healthcare organisation	Independent sector hospital
England	– Internal systems and processes NHS Learn from patient safety events (LFPSE) (NHS England website).	– Local risk management systems (LRMS), NHS National Learning and Reporting System (NRLS) or LFPSE (NHS England website). – Care Quality Commission (CQC) (CQC website).	– Internal systems and processes CQC (CQC website).
Scotland	– Internal systems and processes National Services Scotland  – Report adverse incidents and near-misses involving medical devices, in-vitro diagnostic medical devices, and personal protective equipment.	– Internal systems and processes National Services Scotland.  – Report adverse incidents and near-misses involving medical devices, in-vitro diagnostic medical devices, and personal protective equipment.	– Internal systems and processes. – Healthcare Improvement Scotland website.
Wales	– Internal systems and processes. – NHS Wales Once for Wales Concerns Management System (Datix Cymru) (NHS Wales website).	– Internal systems and processes. – NHS Wales Once for Wales Concerns Management System (NHS Wales website). – Health Inspectorate Wales (HIW) (HIW website).	– Internal systems and processes. – HIW (HIW website).

Legal defences

Pharmacists report various reasons why they find it difficult to report and learn from mistakes. It is estimated that 20% of under reporting is because of fear of prosecution.

Since 16 April 2018, legislation has introduced legal defences to prevent the automatic criminalisation of inadvertent dispensing errors.

The defence is expected to reduce fear of prosecution, underpinning professionalism and confidence so that patient safety is best protected. 

The outcome is to increase the reporting of dispensing errors, the learnings from which could prevent the same error from occurring in the future.

The legal defence against criminal prosecution can be used when the error has been: 

1. Dispensed in a registered pharmacy
2. Dispensed by or under the supervision of a registered pharmacist
3. Supplied against a prescription, PGD or direction from a prescriber
4. Promptly notified to the person once the pharmacy team is aware of the error.

There are plans to introduce similar measures for hospitals and other pharmacy settings and the RPS is working with the Rebalancing Medicines Legislation and Pharmacy Regulation Programme board to ensure that pharmacists in other settings are afforded the same protection.

Updates on the legislation changes to introduce similar measures for hospitals and other pharmacy settings can be found on the DHSC website.

Further information

RCPharm resources

• Clinical audit
• Clinical checks
• Clinical documentation
• Patient Safety Professional Standards: Responding to Patient Safety Incidents
• Medical devices
• MyCPD e-Portfolio
• Polypharmacy
• Pharmacy alerts
• Independent Prescribing (to be added soon)
• Prescribing competency framework
• Professional judgement (to be added soon)
• Repeat prescribing toolkit
• Safe and secure handling of medicines

External resources

Legislation

• Pharmacy (Preparation and Dispensing Errors – Registered Pharmacies) Order 2018

GPhC

• GPhC In practice: Guidance on raising concerns 
• Resources on the professional duty of candour
• FAQs published by the Rebalancing Programme Board
• Standards for registered pharmacies
• Standards for pharmacy professionals

Patient safety

• Care Quality Commission Reporting medicine-related incidents
• Community Pharmacy Patient Safety Group
• Department of Health: Medicine safety: indicators for safer prescribing.
• Healthcare Improvement Scotland Scottish Patient safety Programme
• Healthcare Safety Investigation Branch
• HEE Patient Safety
• Institute for Healthcare Improvement
• Institute for Safe Medication Practices
• Learn from patient safety events (LFPSE) service – (previously called the patient safety incident management system (PSIMS) and is replacing the current National Reporting and Learning System (NRLS) and Strategic Executive Information System (StEIS)
• Medicines Healthcare Products Regulatory Agency (MHRA) Yellow Card Reporting System
• MHRA Alerts, recalls and safety information: drugs and medical devices
• National Patient Safety Agency (NPSA)
• National Reporting and Learning System (NRLS)
• NHS England Never events
• NHS improvement The National Patient Safety Improvement Programmes
• NHS Resolution
• National Institute for Health and Care Excellence (NICE) newsletters and alerts
• Community Pharmacy England (CPE) Patient safety incident reporting 
• CPE Clinical Governance 
• World Health Organisation (WHO) Patient safety (Curriculum Guide)

CD accountable officers 

• Care Quality Commission Register of accountable officers in England
• Healthcare Improvement Scotland Register of Controlled Drugs Accountable Officers (Scotland)
• Healthcare Inspectorate Wales Accountable Officers of Controlled Drugs

Pharmaceutical Journal articles

• Prescribing errors in children: why they happen and how to prevent them – 04 March 2021
• Reducing risk and managing dispensing errors – 01 December 2020
• The top ten prescribing errors in practice and how to avoid them – 21 February 2019
• Medication errors: where do they happen? – 22 February 2019