A patient safety incident can be defined as any unintended or unexpected incident that could or did lead to harm for one or more patients. In a community pharmacy, this includes both dispensing errors and other incidents, such as incorrect advice being provided for an OTC product. While things run seamlessly most of the time, it is important to learn lessons when something does go wrong.

In England and Wales, the National Reporting and Learning System (NRLS) enables patient safety incident reports to be submitted to a single database which covers the whole healthcare system. NHS Improvement manages this system on behalf of the NHS.

Since 2005, all pharmacy contractors in England and Wales have been required to report patient safety incidents to the NRLS. In Scotland and Northern Ireland, local anonymous reporting systems are used, supported by the Healthcare Improvement Scotland Adverse Events National Framework and the Health and Social Care Framework for adverse events in Northern Ireland.

In 2014, NHS England issued a directive recommending that all community pharmacies identify a named medication safety officer (MSO) to review medication incidents and oversee safety improvement within their organisation. Many MSOs are superintendent pharmacists or work in their teams. 

Community pharmacies upload patient safety incident data to the NRLS in different ways. Some will upload data directly to the NRLS as each incident occurs. Others report the incident to their MSO, who will then work with a central office team to collate incident data centrally and conduct internal trend analysis. These teams will then upload all their reports to the NRLS in batches, usually every few months. Unfortunately, because of the way in which the NRLS is set up, this can sometimes result in data going missing or batches being rejected, which skews the overall national picture of reporting.