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Considered by the project team when developing alerts, newsletters and topics to highlight at the development group. In total 12 alerts and three newsletters were sent over nine months see Panel ; . Error reports during the first nine months A total of 56 reports have been received from community pharmacists to date. This includes 10 near misses 18 per cent ; and 46 actual errors 82 per cent ; . The majority of reports were received by post 40, 71 per cent ; , seven 13 per cent ; by fax and nine 16 per cent ; during personal contact at the bimonthly meetings. No pattern of offending drugs has yet been established since the same medication error has not been reported more than once. When the types of errors are considered, the wrong drug was prescribed or dispensed 19 times 34 per cent ; and 15 27 per cent ; were wrong dose strength errors. A further five 9 per cent ; were classified as wrong patient errors, ie, the incorrect patient's name was on the prescription, or another patient's drugs had been prescribed for the patient. Discussion Anonymous reporting of medication errors or near misses appears to have been well accepted by participating community pharmacists. Results indicate that they support the concept of a medication error reporting scheme provided that it is anonymous, easy to use, free and feedback is provided. Respondents were in support of group discussions and multidisciplinary collaboration to prevent error recurrence. Regular alerts and newsletters appear to have been important for feedback, to give constant reminders about the risk of drug errors and to suggest possible changes in practice to minimise recurrence. Participation in the development group and personal visits from the project team also appear crucial to promoting the scheme and ensuring ownership by community pharmacists. The questionnaire reflects opinions of a fairly small number of community pharmacists and it is not clear whether community pharmacists' opinions nationally differ from those reported here. This may warrant further work. Although pharmacists indicated in the questionnaire they saw a median of 97 prescribing, dispensing, or administration errors or near misses annually, reports averaged fewer than two per community pharmacy over the nine-month period. Reasons for this were not assessed but it may reflect residual concerns about confidentiality, litigation, incentives or simply a lack of time. This is in line with voluntary reporting schemes elsewhere.8 Some community pharmacists are recording their participation in this scheme in their continuing professional development portfolios. Since the pilot project commenced, a Department of Health report "Building a safer NHS for patients" recommended that a new integrated approach to learning from medical error, adverse events and near misses be introduced.9 The report suggests that definitions of adverse events and near misses for logging and reporting purposes, formal26 January 2002, because tamsulosin!

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