Society and NPSA in safety project
The Royal Pharmaceutical Society is working with
the National Patient Safety Agency to improve the quality and safety
of patient care. A project concerned with the safety of oral methotrexate
has led to a new Journal feature, “Good Practice Points”.
Catherine Dewsbury, the Society's clinical governance pharmacist, explains
This week sees the launch in The Journal of a new occasional series of “Good
Practice Points” to support the Law and Ethics Bulletins and other
guidance. These good practice points are to help pharmacists improve
and develop their practice beyond the minimum legal and ethical requirements
and ensure that participation in clinical governance becomes easier for
practitioners.
We have chosen methotrexate tablets as our first topic because it gives
an opportunity to promote and explain our work with the National Patient
Safety Agency. The agency is responsible for improving the safety of
patients through confidential and anonymous reporting and learning from
incidents with medicines and developing solutions to reduce the risk
of these happening again.
Both the Society and the NPSA drive to improve the quality and safety
of patient care. Recognising that working together can enhance their
contribution, the two organisations have developed a formal memorandum
of agreement, “Working together to improve patient safety",
which outlines the basis of their collaboration.
One early NPSA project is “Preventing errors with oral methotrexate”,
the aim being to look at problems and identify possible safety solutions.
Published international papers describe both serious and fatal harm to
patients who do not take oral methotrexate as intended. The papers include
cases where the medicine was prescribed and dispensed correctly, but
the patient has “corrected” a perceived error and taken the
tablets daily, despite a weekly dose on the dispensing label.
Other errors are due to “as directed” labelling, which is
particularly dangerous when a third party carer is to administer the
medicines. A warning about weekly dosing would help prevent further deaths
and harm. The NPSA has identified 25 deaths and 26 cases of serious harm
involving oral methotrexate in England in the past 10 years. Of 137 reported
incidents almost half were due to the wrong dosage frequency.
The Society has been helping the NPSA get beyond the literature to access
pharmacists’ experiences with incidents involving methotrexate.
Additionally, the Society participated in the professional reference
group, and in a workshop with professional and patient representatives
to discuss possible safety solutions, such as using a patient diary.
As part of its work with the NPSA, the Society has agreed to update its
Law and Ethics Bulletin item on oral methotrexate and to provide good
practice advice to pharmacists. This advice was developed following the
discussions at the reference group and workshop. We have tried to address
the concerns raised by patient groups and individuals with experience
of methotrexate incidents.
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