PFD report

Judith Lesley Marshall · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 27 Jan 2014•York City

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
7

Raised in this report

Recipients
4

Named on the report

Responses found
4

Of 4 recipients

Stated actions
8

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised7

  1. Uncertainty about availability of prescription-reading software alerts for drug identity or amount errors
    Part of recurring concern: Medication dispensing and dispatch errors not reliably detectedPart of recurring concern: Unreliable clinical safety-alert systemsPart of recurring concern: Unreliable detection and monitoring of prescription errors
  2. Absence of a central database of prescription errors
    Part of recurring concern: Unreliable detection and monitoring of prescription errors
  3. Failure of colleague checking to prevent dispensing medication errors
    Part of recurring concern: Medication dispensing and dispatch errors not reliably detected
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.7

  1. Action

    Review community-pharmacy incident data and relevant research, and engage stakeholders to develop safer-practice guidance on dispensing medicines, technology and checking systems.

    Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 27 January 2014.
  2. Action

    Negotiate the 2014/15 community pharmacy contract to specify minimum patient-safety incident reporting rates and highlight prescribing-error reporting.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 27 January 2014.
  3. Action

    Establish a National Medication Safety Network and identify medication safety officers in large healthcare provider organisations, including community pharmacy companies.

    Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 27 January 2014.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.7

  1. Position

    NHS England is responsible for commissioning pharmaceutical services and has addressed the concerns in its detailed response.

    Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Uncertainty about availability of prescription-reading software alerts for drug identity or amount errors

Wider context from the report

“(3) It is not clear whether there is any software, obtainable from the Department of Health or elsewhere, that could read prescriptions and raise an alert if the label sought to be created or if the drug sought to be dispensed is wrong in identity or amount. This would be of particular significance when a high risk drug is dispensed or when a drug is dispensed in an unusual quantity, dosage or form. ”

Is this part of a recurring concern?

Yes — Medication dispensing and dispatch errors not reliably detected; Unreliable clinical safety-alert systems; Unreliable detection and monitoring of prescription errors.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Absence of a central database of prescription errors

Wider context from the report

“(6) There is evidently no central database of all prescription errors so there can be no central monitoring of such errors and no means of determining trends or particular repeat errors. ”

Is this part of a recurring concern?

Yes — Unreliable detection and monitoring of prescription errors.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure of colleague checking to prevent dispensing medication errors

Wider context from the report

“(2) Despite a system of checking by a colleague it is apparent that there can be a mistake in dispensing medication which in this case was a controlled opiate drug. The consequences were fatal. ”

Is this part of a recurring concern?

Yes — Medication dispensing and dispatch errors not reliably detected.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of mandatory end-of-day reconciliation of prescription-only drugs dispensed against prescriptions

Wider context from the report

“(5) A mandatory check, by a suitably qualified pharmacist or by a third party, at the end of the day after cashing up on the till, of records of each (prescription only) drug dispensed against the prescription would be a further precaution against a repetition of these circumstances. ”

Is this part of a recurring concern?

Yes — Failure to reliably reconcile prescribed and dispensed medication.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of policing of internal pharmacy error records

Wider context from the report

“(1) The Pharmacy’s Errors Book shows a number of drug errors (including higher or lower dose tablets and three wrong drugs) over a number of years. It is not clear whether and to what extent such internal records are policed. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of mandatory read-back procedures for dispensing details

Wider context from the report

“(4) Mandatory procedures requiring a ‘read-back’ of the drug, its dosage, its frequency of administration and its total quantity may prevent such dispensing errors. In so far as the error in this case can be attributable to ‘Human Error’ it is concluded that the dispensing pharmacist focused on the figure of 60 and incorrectly attributed that to the dosage as well as to the number of capsules. ”

Is this part of a recurring concern?

Yes — Failure to verify medication and dose before dispensing; Medication dispensing and dispatch errors not reliably detected; Unreliable medication dosage verification and communication.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of central monitoring and trend analysis of prescription errors

Wider context from the report

“(6) There is evidently no central database of all prescription errors so there can be no central monitoring of such errors and no means of determining trends or particular repeat errors. ”

Is this part of a recurring concern?

Yes — Unreliable detection and monitoring of prescription errors.

Open source report

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Review community-pharmacy incident data and relevant research, and engage stakeholders to develop safer-practice guidance on dispensing medicines, technology and checking systems.

Verbatim wording from the response

“Unfortunately, there is little use of bar codes in the dispensing process in community pharmacy at present. Greater use of this technology in dispensaries could improve patient safety. The Safe Medication Practice Team in NHS England, plan to undertake a review of community pharmacy incident data, together with relevant research and engage with stakeholders to prepare a Patient Safety Alert for possible publication in 2014. The proposed Alert would better describe the risks arising from dispensing medicines and safer practices to further minimise these risks, including better use of technology and checking systems. This guidance will help inform health care commissioners, providers and regulators of actions that they can take to further minimise risks arising from dispensing medicines.”

Source location

2014-0039-Response-by-NHS-England
Page 4 · response
Published 27 January 2014

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Negotiate the 2014/15 community pharmacy contract to specify minimum patient-safety incident reporting rates and highlight prescribing-error reporting.

Verbatim wording from the response

“a) NHS England is in the final stages of negotiating the community pharmacy Contract for 2014/15 and are planning to emphasise the requirement on community pharmacy to report patient safety incidents to the NRLS. We will look to achieve this by stipulating the minimum expected reporting rate and highlighting the requirement for prescribing error.”

Source location

2014-0039-Response-by-NHS-England
Page 3 · response
Published 27 January 2014

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Establish a National Medication Safety Network and identify medication safety officers in large healthcare provider organisations, including community pharmacy companies.

Verbatim wording from the response

“b) NHS England is preparing to publish a Patient Safety Alert on March 2014 to improve reporting and learning of medication errors from all sectors including community pharmacy. This will include the establishment of a National Medication Safety Network, the identification of medication safety officers in large healthcare provider organisations including community pharmacy companies and other measures into to increase the number, quality, timeliness and learning of medication error incident reports.”

Source location

2014-0039-Response-by-NHS-England
Page 4 · response
Published 27 January 2014

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Prepare and publish a Patient Safety Alert to improve medication-error reporting and learning across healthcare sectors, including community pharmacy.

Verbatim wording from the response

“b) NHS England is preparing to publish a Patient Safety Alert on March 2014 to improve reporting and learning of medication errors from all sectors including community pharmacy. This will include the establishment of a National Medication Safety Network, the identification of medication safety officers in large healthcare provider organisations including community pharmacy companies and other measures into to increase the number, quality, timeliness and learning of medication error incident reports.”

Source location

2014-0039-Response-by-NHS-England
Page 4 · response
Published 27 January 2014

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Highlight existing dispensing-error guidance, including involving two people where possible, in the next Regulate+ newsletter.

Verbatim wording from the response

“2. The GPhC has published guidance which contains information about minimising the risk of dispensing errors (http://www.pharmacyregulation.org/sites/default/files/Responding%20to%20complaints%20and%20%20concerns%20.pdf). The guidance explains that two people should be involved in the dispensing process where this is possible. Whilst I understand that in this case, two people were involved in the dispensing process, we can highlight our guidance in the next edition of our newsletter through Regulate+.”

Source location

2014-0039-Response-by-General-Pharmaceutical-Council
Page 2 · response
Published 27 January 2014

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Review whether pharmacy inspections should interrogate recorded dispensing errors more extensively.

Verbatim wording from the response

“1. We set standards for registered pharmacies which focus on the outcomes we expect to see in registered pharmacies. We inspect registered pharmacies against the standards and produce reports of our findings.”

Source location

2014-0039-Response-by-General-Pharmaceutical-Council
Page 2 · response
Published 27 January 2014

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Continue working with MHRA and NHS England to ensure pharmacy professionals use the National Reporting and Learning System.

Verbatim wording from the response

“6. The medicines regulator, the MHRA, has been working with NHS England to develop draft Patient Safety Alerts and guidance to increase adverse incident reporting via the National Reporting and Learning System (NRLS), which is a central database of patient safety incident reports. We continue to work with the MHRA and NHS England to ensuring that pharmacists and pharmacy technicians use the NRLS.”

Source location

2014-0039-Response-by-General-Pharmaceutical-Council
Page 2 · response
Published 27 January 2014

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

NHS England is responsible for commissioning pharmaceutical services and has addressed the concerns in its detailed response.

Verbatim wording from the response

“As Secretary of State for Health, I am responsible for setting national priorities, monitoring the whole system’s performance and supporting the integrity of the system to protect the best interests of patients, the public and the taxpayer. Since 1 April 2013, most day to day decisions are taken by NHS England. NHS England is responsible for commissioning primary care services, including pharmaceutical services.”

Source location

2014-0039-Response-by-Department-of-Health
Page 2 · response
Published 27 January 2014

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Mandatory read-back procedures are not introduced because definitive evidence that they reduce dispensing errors is lacking.

Verbatim wording from the response

“4) Mandatory procedures requiring a ‘read-back’ of the drug, its dosage, its frequency of administration and its total quantity may prevent such dispensing errors. In so far as the error in this case can be attributable to ‘Human Error’ it is concluded that the dispensing pharmacist correctly had the figure of 60 and incorrectly attributed that to the dosage as well as to the number of capsules.”

Source location

2014-0039-Response-by-NHS-England
Page 3 · response
Published 27 January 2014

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The National Reporting and Learning System is a central database for prescription errors, although community pharmacies underreport incidents.

Verbatim wording from the response

“6) There is evidently no central database of all prescription errors so there can be no central monitoring of such errors and no means of determining trends or particular repeat errors.”

Source location

2014-0039-Response-by-NHS-England
Page 3 · response
Published 27 January 2014

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Community pharmacists, pharmacy staff and General Pharmaceutical Council inspectors are responsible for reviewing pharmacy incidents and addressing identified risks.

Verbatim wording from the response

“Community pharmacies are required to record patient safety incidents that caused harm or have the potential to cause harm in a pharmacy errors log. They should also report these incidents to the National Reporting and Learning System (NRLS). The aim of recording and reporting incidents is to identify risks to patient safety and ensure that they are addressed both locally and nationally. Community pharmacists and their staff have responsibility to reflect on patient safety incidents that occur and identify safer practice to address these risks. Health care teams and governance systems should be in place to ensure this occurs. In a community pharmacy the responsible pharmacist and superintendent pharmacist have a particular responsibilities in this regard.”

Source location

2014-0039-Response-by-NHS-England
Page 1 · response
Published 27 January 2014

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Mandatory end-of-day prescription reconciliation is not introduced because evidence that it reduces dispensing errors is required.

Verbatim wording from the response

“5) A mandatory check, by a suitably qualified pharmacist or by a third party, at the end of the day after cashing up on the till, of records of each (prescription only) drug dispensed against the prescription would be a further precaution against a repetition of these circumstances.”

Source location

2014-0039-Response-by-NHS-England
Page 3 · response
Published 27 January 2014

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The regulator cannot require registered pharmacies to use automation to reduce dispensing errors.

Verbatim wording from the response

“3. There is research that shows the use of automation within a dispensing process can reduce the rate of errors. Whilst we cannot require registered pharmacies to use automation, we do ensure that the way in which we regulate does not stifle the introduction of new technology.”

Source location

2014-0039-Response-by-General-Pharmaceutical-Council
Page 2 · response
Published 27 January 2014

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The central prescription-error database is held by NHS England, which is expected to provide the relevant details.

Verbatim wording from the response

“• Regarding a central database of prescription errors, we are pleased to report that this does exist. The national learning and reporting system sits with NHS England and we expect they will be providing details of this within their response to you. http://www.nr ls.npsa.nhs.uk/”

Source location

2014-0039-Response-by-Royal-Pharmaceutical-Society
Page 2 · response
Published 27 January 2014

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. 1

    Consider publishing an anonymised case summary and learning points in a forthcoming Regulate newsletter.

    Stated by General Pharmaceutical CouncilStated plannedThe respondent said that this action was planned when they made their response on 27 January 2014.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.2

  1. 1

    The Royal Pharmaceutical Society is well placed to provide pharmacists with guidance on this area.

    Stated by General Pharmaceutical CouncilRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
  2. 2

    Regulatory action falls outside the Society’s powers; it can assist only through observation.

    Stated by Royal Pharmaceutical SocietyOutside remitThe respondent said that this matter was outside its role or authority.

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Consider publishing an anonymised case summary and learning points in a forthcoming Regulate newsletter.

Verbatim wording from the response

“4. We are considering publishing a high level summary of the case you have described to us (fully anonymised of course) in one of the next editions of our newsletter ‘Regulate’, which goes to all registered pharmacists and pharmacy technicians 6 times per year. Regulate contains a section entitled ‘learning points’ where we use case studies to highlight important safety and standards points.”

Source location

2014-0039-Response-by-General-Pharmaceutical-Council
Page 2 · response
Published 27 January 2014

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The Royal Pharmaceutical Society is well placed to provide pharmacists with guidance on this area.

Verbatim wording from the response

“5. There are a number of organisations that provide guidance and advice to pharmacy professionals, and the professional body for pharmacists, the Royal Pharmaceutical Society (RPS) are well placed to provide guidance to pharmacists on this area.”

Source location

2014-0039-Response-by-General-Pharmaceutical-Council
Page 2 · response
Published 27 January 2014

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Regulatory action falls outside the Society’s powers; it can assist only through observation.

Verbatim wording from the response

“We understand the matters of concern which you have raised, and whilst we do not have regulatory powers, we are keen to assist through observation where this is helpful. Our observations on the concerns you have raised are as follows.”

Source location

2014-0039-Response-by-Royal-Pharmaceutical-Society
Page 1 · response
Published 27 January 2014

Open published response
Back to top

Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026