Incidents analysed by pharmacists’ peers
Pharmacists in Scotland have been benefiting from a scheme to improve safety and provision of patient care via formal peer review analysis of significant events. The scheme was launched six months ago by NHS Education for Scotland (NES) and so far 31 incidents have been reported.
The scheme provides the chance to use incidents, near-misses made in
practice and particularly well-managed events as learning opportunities.
All pharmacists in Scotland are being encouraged to complete and submit
significant events analysis (SEA) as a tool for learning, improving patient
safety and managing health care risk.
“If an event is simply acknowledged and discussed informally and
in an unstructured manner among colleagues after it happens it is possible
it could recur. SEA allows structured analysis of the incident so that
a clear picture of what happened is established, insight into the event
is demonstrated, educational needs are identified and addressed, and
lessons are learnt. The chances of it recurring should be minimised,” explained
Ailsa Power, assistant director of pharmacy at NHS Education for Scotland.
The scheme is already used by doctors, particularly GPs. Ms Power pointed
out that many significant events relate to medicines and hence in practice
will involve both pharmacy and medical professionals. Extending this
peer-review scheme to pharmacists means that identification of events
for both professions will occur. “This will facilitate multidisciplinary
working in terms of research and identification of training initiatives,” said
Ms Power.
Pharmacists must complete a confidential written report of the event,
answering the following questions: what happened; why did it happen;
what changes to practice have I implemented; and what have I learnt?
NES-trained pharmacists in each NHS board in Scotland form a peer review
network that provides individual and confidential feedback on submitted
forms. The strength of this system is the peer review element, since
the reason for an event occurring may be missed by the submitting pharmacist,
added Ms Power.
Further information
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