Learning from Incidents Newsletters

September 2019

• Communications between Pharmacies and Substance Misuse Services
• Signposting to Specialist Pharmacies for ‘End of Life’ (EOL) Medication
• Common Dispensing Incidents

February 2019

• Gabapentin/Pregabalin Rescheduling
• Opioid Administration/Prescribing Issues
• Incarcerated Patient Related Issues

August 2018

• Opioid use in long term pain
• Gabapentin/pregabalin drug related deaths
• Oromorph given subcutaneously
• CQC annual report
• Lost Prescriptions
• Annual CD declaration

March 2018

• Burglaries to pharmacies
• Delivery errors
• Alcohol-free phenobarbital liquid for children
• Post-dated prescriptions
• Denaturing reminder
• Dealing with lost or stolen prescriptions

November 2017

• Gabapentin/Pregabalin consultation
• Common CD prescribing/dispensing incidents
• Recent burglaries to pharmacies

August 2017

• Reporting incidents
• Post-dated CD prescriptions dispensed too early
• Patients with protected addresses
• Midazolam injection for palliative care
• What can happen when things go wrong when prescribing for chronic pain

April 2017

• Reporting of illicit drug reactions RIDR
• Diversion of prescription medicines

February 2017

• Destruction of Controlled Drugs
• Examples of suppliers of CD denaturing kits
• CD balance checks during external stocktaking
• Licensed equivalents for special order CDs

 November 2016

• Prescribing and supply of controlled drugs
• Advice to Community Pharmacies re the delivery of medicine
• Advice for practices re the security of controlled drug prescriptions
• NICE Guideline NG46: The safe use and management of controlled drugs

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July 2016

• Prescribing for temporary residents
• CD incidents reported on SIRMS January – March 2016
• Common prescribing and dispensing incidents

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February 2016

• Medicines for palliative care
• What to do with unused medicines when a patient dies

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