| · The Society
· Pharmacy education
· Patient safety
· Statins
· Dispensing
· Packaging
· Resources
Letters to the Editor
|
Patient safety
Fair and open culture is key to success of reporting schemes
From Ms W. E. Harris, MRPharmS
Alan Nathan’s article raises several interesting points regarding
the reporting of patient safety incidents by pharmacists.
The National Patient Safety Agency (NPSA) has developed the National
Reporting and Learning System (NRLS) to ensure the anonymity of health care staff
and patients. We will not store information about staff or patients involved
in reported incidents. If attributable data is sent in error, specially
developed software will remove names of individuals or pharmacies before
storing it on our NRLS database.
We are supportive of the Royal Pharmaceutical Society’s approach
in seeking to remove the criminal status of a dispensing mistake which,
in future, would offer the protection that pharmacists might need.
We will analyse and publish statistics from the incident data we collect
to promote a learning culture within the NHS. These statistics will be
at a sufficiently aggregate level to ensure that the identity of an individual
cannot be inferred. These measures both respect the guarantee of anonymity
under which the patient safety incident data were originally submitted,
and ensure full compliance with the Data Protection Act.
Patient safety quality measures are being discussed within the proposals
for the new pharmacy contract, including the reporting of medication, prescribing
and dispensing, and administration-related patient safety incidents to
the NPSA through the NRLS. (A patient safety incident is any unintended
or unexpected incident which could have, or did, lead to harm for one or
more patients receiving NHS-funded care — this is also referred to
as an adverse event or medication error, and includes near misses.) We
welcome this opportunity to focus on patient safety within the new contract,
since it places the emphasis firmly on the pharmacist’s vital role
in protecting the safety of patients in relation to medicines.
While negotiations on the contract are still ongoing, many community pharmacy
companies and organisations have already begun to build their capacity
to collect this information, for company and individual learning.
Similarly, some NHS organisations have also begun to establish local schemes,
such as the SafeMed scheme described within the article. Early schemes
vary in that some concentrate upon dispensing errors and only include community
pharmacists, while others are wider both in remit and focus. The key success
factor for any reporting scheme, whether local or national, is that it
operates within an open and fair culture and is confidential and non-punitive.1
Consequently, the NPSA is taking a pragmatic approach in exploring the
best ways for community pharmacies to report incidents nationally, which
might include direct reporting to the NPSA using an electronic form; or
reporting through the local primary care organisation’s or company’s
existing systems which will be integrated with the NRLS. It is vital that
we establish the right reporting systems to support this at a national
level, and that we take the time to get this right.
Many community pharmacy companies already collect dispensing error information
for corporate governance purposes, and we know that there is a real willingness
among pharmacy staff in other settings to report when things go wrong.
Of course all of these developments to collect information will only be
worthwhile if they improve patient safety. Much learning can be achieved
at local level within individual pharmacies and across primary care organisations.
However, there will be some solutions which require a national perspective.
The article specifically mentions problems with methotrexate for which “there
is currently no national guidance”. The NPSA will be alerting the
NHS about methotrexate shortly and this work would probably not have reached
this conclusion without information from existing reporting schemes on
the frequency and type of incidents occurring. It is certain that if the
NPSA is to successfully develop solutions at a national level, such as
safe medicine packaging designs, incident reports will be a crucial information
source.
In undertaking their professional role and being the experts in medicines,
pharmacists have always been the traditional advocates of patient safety.
We are committed to involving them in the issues we identify and the solutions
we develop to improve the safety of patients.
Wendy Harris
Senior Pharmacist, Clinical Programmes,
National Patient Safety Agency
Reference
1. Leape LL. Patient Safety: reporting of adverse events. New England
Journal of Medicine 2002:347:1633–8. |
The
Pharmaceutical Journal