Primary Care Pharmacists Association
Risks must be designed out or managed
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The Primary Care Pharmacists Association annual
conference took place in Leeds, from 16 to 17 September. The conference
focused on the management of risk associated with the use of medicines.
Dr Duncan Jenkins, public relations officer, PCPA, reports
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Asking pharmacists simply to be more alert is not sustainable. They need
to be encouraged to develop action plans, said Steve Eastham, head of
clinical governance at Boots the Chemists Ltd. He stated that the Boots
principles included designing out risks as far as possible, managing risks
as they arise and learning from mistakes when they happen. He emphasised
that recording, monitoring and communicating best practice are all useless
unless behaviours in the pharmacy change, and that different pharmacies
require different solutions. Mr Eastham added that everyone at all levels
must understand the aims of incident reporting. He also stated that applying
targets, singling out individuals or jumping to conclusions could all
inhibit change.
When questioned on the potential for Boots to share incident reports with
primary care trusts, Mr Eastham said that because of commercial sensitivities,
Boots would be reluctant to share any data unless the National Patient
Safety Agency instructed it to do so.
PCTs and community pharmacy clinical governance
Sue Mills, a pharmaceutical adviser with the West Sussex pharmacy team,
provided some insight into the working of the Commission for Health Improvement
(CHI). Mrs Mills is one of a number of pharmacists who work for CHI on
short-term secondments to their review teams. She stated that a CHI review
of a PCT consists of a 17-week process that starts with examination of
the trust’s data and documentation, includes a number of meetings
with trust staff and other stakeholders and concludes with the publication
of a report. Mrs Mills said: “It is not a service review. CHI are
looking at the processes and policies an organisation has in place to
deliver the clinical governance agenda.”
When considering community pharmacy issues, the PCT will be assessed on
a number of factors, said Mrs Mills. She described how CHI will seek evidence
of a clinical governance lead for community pharmacy and how that lead
relates to and communicates with the PCT board. “They will also want
to know how the trust actively supports clinical governance work in community
pharmacy, for example, with risk management and multidisciplinary audit,
and how the views of contractors are represented within the organisational
structure.” She went on to say: “CHI will also ask how PCTs
deal with poor practice, though it is acknowledged that this is difficult
unless there is a complaint.” Other factors Mrs Mills said CHI would
be interested in included workforce planning, education and training,
the use of information, public involvement, management of complaints and
complements, and patient privacy and dignity in community pharmacies.
Non-pharmacy perspectives
Jon Horrocks, associate director of Ove Arup Ltd, a prominent civil engineering
company, provided the first non-
pharmacy perspective of risk. Mr Horrocks defined risk as “a function
of probability of a hazard occurring and the resulting impact of it occurring”.
The use of a red-amber-green system of grading risks in the civil engineering
industry is the same approach to that taken by the NPSA. Mr Horrocks stated:
“Some risks are acceptable as amber, though red risk [high probability,
high impact] must go.” He emphasised that every project has risks.
“Risks must either be designed out, or we must have a contingency
plan to deal with identified risks. When unforeseen risks arise, we must
manage the process.” Summarising, Mr Horrocks advised that “in
pharmacy, risks with a project should be brainstormed from the start,”
and there should be regular “risk warnings meetings”.
Dr Rebecca Lawton, a psychologist from the University of Leeds, provided
lessons from the rail industry. Dr Lawton stated that a principal aim
of any intervention is “first do no harm”. She went on to add:
“The problem is we are human beings and it is within our nature to
make errors.” She said that errors can fall into two categories.
The first is “execution errors” or slips and lapses, the second
is “planning failures” or mistakes. She differentiated between
errors and violations, stating that errors arise from information processing
whereas violations, deliberate deviation from procedures or guidelines,
arise from motivational problems. A further distinction was made between
active and latent failures, the former being “unsafe acts of those
at the sharp end,” and the latter being “decisions of those
removed from the day-to-day operations”. Dr Lawton stated that active
failures have immediate consequences and are difficult to predict. In
contrast, latent failures lie dormant within the system and can be identified
and remedied proactively.
Dr Lawton made a final distinction in the way errors are managed. First,
she described the person approach, which focuses on an individual’s
active failures and where the remedy is to remove the individual from
the system. Secondly, she described the systems approach, which focuses
on latent failures and assumes errors are consequences rather than causes
and are managed proactively by identifying how and why error defences
fail. Dr Lawton advised the pharmacy profession that the discovery of
errors requires a true blame-free culture and to prevent errors, pharmacists
should avoid too many rules and regulations. She also emphasised that
organisational learning should be both reactive and proactive.
Learn from our mistakes
Building on the theme of organisational learning, Dr Bryony Dean, principal
pharmacist from Hammersmith Hospitals NHS Trust and the School of Pharmacy,
University of London, discussed how monitoring and reporting can reduce
medication errors. Referring to some of her own research, Dr Dean said:
“It is estimated that medication errors result in permanent damage
or an increased length of hospital stay in about 1 to 2 per cent of hospital
patients.” She went on to say that more is known about the incidence
of medication errors in secondary care than in primary care. She discussed
two ways of gaining information on medication errors: incident reporting
methods and observation methods. The former, she said, resulted in under-reporting
of errors. A study by Barker and McConnell in the United States had shown
that only 1 in 1,400 incidents were reported. On the other hand, she said
that with observation methods, although more complete data could be collected,
they are labour intensive and potentially intrusive.
Dr Dean stressed that there is little evidence as yet to show that monitoring
and reporting can reduce errors. “Monitoring and reporting [on a
local and national level] can only reduce errors if findings are fed back
to those involved and changes are made to the systems involved.”
She recommended feeding back both individual and collated reports to staff
and stressed the need to identify changes required. This, she said, could
include error producing conditions, such as constant disruptions or similar
packaging of different products, or latent failures such as staffing levels
or deficiencies in education and training provision. During the discussion
that followed Dr Dean’s presentation, Professor Joy Wingfield, University
of Nottingham, commented on the need for the Royal Pharmaceutical Society’s
disciplinary process to be more consistent with the systems approach which
places emphasis on learning from mistakes rather than punishment. She
said: “We need to feed this through to the disciplinary process.
If a patient complains the matter can go straight to the top.”
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