Council seeks decriminalisation of dispensing errors
Dispensing and labelling errors should be decriminalised to make it easier to treat them as learning opportunities, the Council of the Royal Pharmaceutical Society has decided on the recommendation of its Infringements Committee.
At the December
Council meeting, the Council agreed to start the process
of seeking a change to legislation to decriminalise such errors. Because
the process will take time to effect, the Council also agreed that, in
the meantime, it would revise the current criteria to prevent referral
to the Statutory Committee of matters that do not bring a pharmacist’s
fitness to practise into question.
The Council had before it a discussion paper prepared jointly by the
Fitness to Practise and Legal Affairs Directorate and the Practice and
Quality Improvement Directorate. The paper pointed out that pharmacists
commit a criminal offence each time they make a dispensing error or labelling
error. If such an error is reported to the Society, the pharmacist is
informed that it may lead to their removal from the Register or the imposition
of some other sanction by the Statutory Committee — although in
practice it is more likely to lead to no further action by the committee.
The impact of all this on the pharmacist can be devastating and, as a
result, there is serious under-reporting of errors and near misses. This
precludes the opportunity to use these incidents as learning opportunities
to reduce the number of errors in the interest of patient safety. This
is in conflict with the Society’s key role of public protection.
The paper said that the Society has a duty under the Medicines Act to
enforce various provision of the Act, and the Infringements Committee
has a statutory duty under its Procedure Rules to consider all alleged
infringements brought to its attention. It refers to the Statutory Committee
only those cases in which there is a real prospect of establishing misconduct
which would render the person concerned unfit to remain on the Register.
During 2006 the committee has been unable to keep pace with the number
of new cases being received and it has agreed extra sittings in 2007
to help clear the backlog. Yet research has shown that only a small fraction
of dispensing errors are reported to the Society. Reasons for this under-reporting
include fear of being disciplined and loss of self-esteem. The researchers
found a “prevailing blame culture in which incidents were routinely
covered-up, preventing any opportunity for organisational learning”.
The blame culture appeared to lead to pharmacists being reluctant even
to report incidents to the National Patient Safety Agency, where such
referrals are anonymised.
The paper said that this was a problem for the Society because one of
its key roles was protection of the public. Initiatives to improve patient
safety stressed the need to obtain comprehensive information on adverse
events so that it can be used as a source of learning and to prevent
recurrences. But thousands of such learning opportunities were lost locally
each month, thereby precluding the realisation of widely applicable solutions.
The paper said that the Infringements Committee recommendations would
alleviate the situation in the short term while at the same time enable
a longer term and more comprehensive solution to a long-standing problem.
These steps were necessary to encourage open reporting by pharmacists
of all errors and near-misses, so that the necessary learning can take
place in the interests of patient safety, and to enable the Society to
take a more risk-based approach to complaints by distinguishing those
errors that should properly call the pharmacist’s registration
into question from those that do not.
|
The
Pharmaceutical Journal