Patient Safety

Community Pharmacy Patient Safety Group

The Community Pharmacy Patient Safety Group provides a forum for community pharmacy organisations, competitors in a commercial sense, to openly share and learn from each other when things go wrong, as well as from other sectors and industries.

They consider how learning from patient safety incidents can be applied across the pharmacy network and wider NHS, and then create the opportunities and resources to do just that.

You can visit their website at

NHS Improvement

Just Culture Guide

Scenarios to support training in using a just culture guide

LEARNING: Important safety information regarding Communication of Urgent Prescriptions between Healthcare Professionals

A good relationship and communication between healthcare professionals ensure seamless care for patients and promotes patient safety.

Following an unfortunate incident, whereby a patient did not receive their prescription for urgent antibiotics, the learning for GP and Pharmacy teams is the importance of good communication by all involved.

“After a home visit the GP returned to the practice and issued an EPS prescription for antibiotics, knowing the pharmacy offered a delivery service. This was received, downloaded and sent to print by the pharmacy, however the token either did not print due to a printer error or was lost.  The prescription was never labelled and so the alert on the PMR indicating the patient required delivery was not seen. There was no record of a verbal request from the GP, patient or patient’s family to deliver the antibiotics urgently and so as the pharmacy team were not aware of the existence of the prescription, the antibiotics were never supplied. “

Only by sharing the learning from such incidents does it give other pharmacy teams the opportunity to reflect on their processes, communication and ways of working with the local surgery. Focus could be isolated on changes to the EPS system – NHS Digital and the PMR suppliers have reflected on the incident and consulted on what they may do in the future, but this incident could have been prevented had the pharmacy team known there was an urgent prescription to dispense. In this pharmacy there was a communication book in use, recording any requests for delivery. The entries were checked against the delivery log at the end of the day to make sure all deliveries were accounted for.

The learning is that urgent messages/requests for urgent deliveries must be conveyed either face to face or by telephone conversation. Now reflect on the relationship and ways of working in your area, between local surgeries and pharmacies and plan any improvements to reduce the risk of a similar incident.