Strategic systems and good practice can protect pharmacy teams and patients from many risks. However, the Swiss cheese model (discussed in Module 3) will still apply, as other potential gaps and weaknesses in the system are inevitable. Therefore, it’s important to be riskaware, keeping up to date with incident reports from elsewhere, reinforcing the ideals of being open and actively looking for risk and the potential to reduce it. These are all features of a good safety culture and should make communication easier and help identify and address any misunderstandings before they lead to incidents. A good safety culture also means sharing information openly and freely and ensuring fair treatment for staff when an incident happens.

Change is inevitable. As a result, pharmacy teams should be continuously improving and monitoring the effectiveness of their risk management strategy, demonstrating that they are making appropriate efforts to assess and manage risk, seek feedback about how effective the risk management is and looking to improve it. This may involve reviewing incidents and/or risk assessing the normal pharmacy processes for their potential to do harm.