Fear stops pharmacists reporting dispensing errors
Community pharmacists and their support staff are unlikely to report adverse incidents occurring on pharmacy premises, according to research carried out at the University of Manchester and published in Quality
and Safety in Health Care this week (2006;15:48).
The researchers conclude that community pharmacists and their staff are
not convinced that the advantages to them and to patients of reporting
patient safety incidents outweigh possible consequences and blame.
However, the finding has been questioned by the National
Patient Safety Agency. Wendy Harris, NPSA head of safety solutions and a pharmacist,
said that incident reports from community pharmacies are running at 400
to 1,000 a month and are growing exponentially.
Half of the reports were of dispensing errors and 1 per cent resulted
in serious harm. This harm ratio was comparable to reports from all other
professional sources.
“This really shows pharmacists’ willingness to share with
us in an anonymous and confidential way,” Ms Harris said. “Our
experience is that, compared with other professions and NHS organisations,
pharmacy’s reporting rate is very, very good.”
However, she warned: “There is still a blame culture in the profession.
This is something that our professional body needs to think about long
and hard. Pharmacists do not set out to do harm.”
The University of Manchester researchers set out nine hypothetical scenarios
involving different types of error and differing severity of outcome
for patients. They found that support staff were generally less likely
than pharmacists to report incidents and that both were less likely to
report incidents to the National Patient Safety Agency than to report
them internally. In almost all cases, the likelihood of reporting an
incident increased with severity of outcome.
The researchers attribute their findings to a disparity between the prevailing
culture in community pharmacy and national policy that mistakes should
be reported so that lessons can be learnt across the NHS.
“Adverse incidents in community pharmacies are associated with
less than satisfactory performance and reporting incidents is associated
with the
attribution of blame,” they say. “The key to success will
be to develop a reporting culture in which staff feel able to report
incidents without fear of retribution.” They point out that this
will be difficult so long as dispensing errors remain a potential criminal
offence under the Medicines Act 1968. |
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