Pharmacists are "substantially" under-reporting patient safety errors and must work to address this, NHS England has warned.

Only 7,919 medication incidents were reported by community pharmacies in England and Wales in 2012, despite an estimated 12.7 million serious incidents involving prescribing and dispensing errors having occurred during the same period, NHS England research into the NHS's National Reporting and Learning System (NRLS) found.

The incidents reported included "prominent" examples of errors occurring despite clear national guidance to prevent them, NHS England said in a review published last week (July 15).

Nineteen incidents were classed as ‘severe' and 33 as ‘moderate', the commissioning body said. There was only one report of a fatal incident, when MST 30mg was dispensed in place of 10mg.

As part of their contract with NHS England, pharmacies are expected to keep a patient safety incident log and a ‘near miss' log. NHS England estimated that pharmacies had enough time to report one incident a day in addition to their maximum workload.

The culture of reporting incidents needed to be improved to reduce avoidable harm, NHS England said. Some community pharmacists felt it was only necessary to report an incident if a patient was actually harmed, but this was "not the ethos" of the NRLS, it added.

More than 95 per cent of incidents reported by community pharmacists were due to a dispensing error. These were caused by confusion when medicines sounded or looked too similar, NHS England said.

NHS England senior pharmacist Dr David Gerrett said failing to report patient safety incidents was "not an option" for pharmacists and called for the sector to take advantage of technology to reduce the number of errors.

"We are desperate that pharmacists take on board new technology for barcode scanning. If you take a barcode reading [of a medicine] you are less likely to have a ‘look alike, sound alike' error," he told C+D.

Pharmacists could report incidents through the online form on the NRLS website, NHS England said. However, the quickest option is for pharmacists and hospitals to share their incident report data and submit it via a batch report to the NRLS, it added.

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