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Reporting near misses
Stand by your beds

Reporting near misses

The Commission for Health Improvement, in one of its recent reports, called on hospital trusts to record and monitor pharmacists’ interventions on prescription charts (see p313). These were, in fact, near miss medical errors and should be recorded as such, it suggests.

Hospital pharmacists, like all other pharmacists, will be increasingly called on to justify their existence. They will need to start recording the interventions they make, the reasons for them and the outcomes, and use this information to persuade policy makers and budget holders of their value.

However, not all the interventions made by pharmacists could really be described as having averted medical errors. Minor corrections of spelling or product names are at one end of a scale; the prevention of lethal overdoses or major interactions are at the other. Hospital pharmacists need to be allowed to follow up the interventions that matter rather than noting every last minor change. To this end, the gradual introduction of electronic prescribing systems should help. These should be able to reject or weed out some of the more common and obvious errors leaving pharmacists free to concentrate on major problems and discuss them with the original prescriber.

Of course, when hospital pharmacists become prescribers, someone else will need to follow behind them checking up on all their near misses.

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Stand by your beds

New proposals from the Government for patient scrutiny of National Health Service activities could lead to community pharmacy contractors receiving unannounced inspections of their premises (see p315). These visits would be in addition to those made by the Royal Pharmaceutical Society’s own inspectors.

The PSNC has expressed concern about these new powers of inspection, saying that nothing should be allowed to disrupt the smooth operation of dispensing within pharmacies, a justifiable safety concern.

The Government is community pharmacy’s main paymaster and it has a right to demand to know how services are being operated in its name. Unannounced inspection visits are always the most effective because they can reveal problems that might otherwise be covered up. The reports by the Commission for Health Improvement (see above) show how a fresh pair of eyes can see things in a different light.

Well run pharmacies have nothing to fear, have they?

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