Minimising and managing risk in the pharmacy is a matter for all members of the pharmacy team, says the NPA’s head of pharmacy services Leyla Hannbeck

Recently, NHS England issued a patient safety alert outlining changes to arrangements for the reporting of medication safety incidents in England. This included the requirement for pharmacy businesses in England to appoint a medicines safety officer (MSO). The MSO, usually the superintendent pharmacist, will oversee medication error incident reporting and learning.

The NPA’s head of pharmacy services, Leyla Hannbeck, is acting as the MSO for all independent community pharmacies in England with less than 50 branches. Leyla will be responsible for supporting pharmacy businesses and superintendents to:

• Promote the safe use of medicines across the pharmacies
• Implement local and national medication safety initiatives
• Improve patient safety on a day-to-day basis
• Submit medication error reports to the National Reporting and Learning System (NRLS)
• Improve reporting and learning from medication incidents
• Respond to requests from the Patient Safety Domain in NHS England, and Medicines and Healthcare products Regulatory Agency (MHRA), for information about medication error incidents.

In addition, Leyla will ensure that medicine safety communications from NHS England and the MHRA are cascaded to pharmacy businesses with less than 50 branches.

Recording errors

To log patient safety incidents within the pharmacy, NPA members can use the Patient Safety Incident report form. Records should include both actual and potential errors. It is important to understand at which point in the dispensing process the actual or potential error occurred.

For example at the prescribing stage, during preparation or dispensing, in administration or supply of a medicine from a clinical area, in giving advice, or incorrect supply or use of an OTC medicine. Similarly, records should include an appropriate description of the incident. It is useful to consider other important factors in the actual/ potential error, too.

For instance, was there poor transfer of communication between paper and electronic records? Was there a break down in communication? Did the patient or carer fail to follow instructions?

Learn and act

Pharmacy staff should understand the difference between a ‘nearmiss’ and an incident. A near-miss describes an incident that was resolved without involving the patient. For example, the final check identified the problem.

In the case of an incident that didn’t cause any harm, there are two possibilities. ‘Impact prevented’, is where the patient safety incident had the potential to cause harm but was prevented, resulting in no harm to the person receiving the care. Alternatively, impact may not have been prevented, but no harm occurred to the person who was receiving the care.

Action taken following an incident may include additional training, identification of high-risk products, shelf warnings or a review of procedures. It is also very important that all staff know how to deal with complaints arising from pharmacy services and that they are familiar with the pharmacy complaints SOP.

For more information, NPA members can contact the pharmacy services team on: 01727 891800 / 0844 7364201 or email: pharmacyservices@npa.co.uk.