The Pharmaceutical Journal
Vol 279 No 7481 p639
8 December 2007

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Community pharmacy must improve incident reporting

Community pharmacists are being urged to increase their reporting of patient safety incidents. At a conference on patient safety and risk in London last week, Jane Moore, a director of health care quality for the Department of Health, told delegates that their challenge was to increase the number of reports coming from community pharmacists and GPs.

National Patient Safety Agency data from April 2006 to March 2007 show that acute and general hospitals continue to be the highest reporters while workers in primary care barely report at all, she noted.

“Why do we have significant under-reporting in primary care when 90 per cent of patient contacts are in primary care,” she questioned. She accepted that the reasons are complex: “It is more difficult to report the data and there has not been [the same] degree of collective interest in primary care.”

She suggested increased efforts were needed to persuade both groups that their reporting would make a difference. If they could be shown that reporting had wider uses, such as reducing complaints and litigation, that might also help.

Philippa Rogers, principal pharmacist, Conwy and Denbighshire NHS trust, has overseen changes to the dispensing process as part of the Safer Patients Initiative, a scheme funded by the Health Foundation (PJ, 28 July 2007, p95).

Ms Rogers said at the conference that the trust used failure mode and effects analysis to reduce errors, such as prescriptions and requests becoming separated from inpatient charts, communication failures and human error.

The analysis identified the causes of such mistakes as being around a lack of clinical checking training for pharmacists, a need for better inductions, a need for a good skill mix of staff and a lack of awareness of dispensing errors. Increased training, changes to rotas and a graph of errors was displayed in the pharmacy department as ways to deal with these problems, Ms Rogers explained.