Our thoughts on today’s news about medication errors
Victoria Steele, our head of clinical governance and professional standards as well as the organisation’s Medication Safety Officer, talks about today’s news about drug errors.
It was upsetting to read about the study which suggests that GPs, pharmacists, hospitals and care homes may be making 237 million errors a year – especially when we consider the potential harm and distress this causes patients and their families.
Pharmacists are caring healthcare professionals who are an intrinsic part of the multi functional teams in all fields of healthcare, supporting patients to lead better, healthier lives. Sadly, dispensing errors do occasionally occur and in my role, my team and I review and support investigations on these. We see first-hand the impact on patients, their families – but equally our pharmacists and teams. No health care professional sets out to make a mistake and the pharmacists I deal with are extremely worried by the potential or actual harm that could be caused to a patient.
There is a massive discrepancy between the study findings and the number of reported incidents, so we should perhaps focus on a number of thoughts from the report; how we encourage people to report, learn and share from their mistakes. Equally, ensuring that communication and collaboration is open and transparent between all health care professionals involved in a patient’s care, which can only improve patient outcomes.
As pharmacists, patient safety is our business and at LloydsPharmacy, we put it at the heart of what we do. That’s why we introduced our SaferCare programme in 2013.
A true safety culture is one in which everyone takes responsibility for patient safety, whatever their role in the business. The absolute essential cornerstones of embedding an effective safety culture are openness and accountability. Through SaferCare we encourage our people to share information freely, report on near misses and highlight when things go wrong, so we can put them right, and learn from these incidents together.
In pharmacy, this will be helped by the forthcoming legislation that will decriminalise dispensing errors.
Although volumes have increased considerably and the role of the pharmacist is significantly different, we should bear in mind that dispensary design has changed little over the decades. We are still working in the same way and we are still largely paid by volume so the emphasis is on rapid turnaround of prescriptions. The introduction of the Quality Payment Criteria is a positive step forward.
Our LloydsPharmacy SaferCare process is about enabling thorough and good quality investigation into patient safety incidents. SaferCare requires pharmacy teams to delve deeper to establish the root cause —or causes— and facilitates coming up with solutions to prevent similar future incidents.
It’s important that today’s report doesn’t undermine relationships between health care professionals and patients. Acknowledgement of the extent of the issue is important, but the next steps must focus on education, not blame. In community pharmacy it is vital that we play our part by supporting our pharmacy teams to share and report any incidents, and then commit time to analysing and learning from them. That way we can reduce errors and enhance patient care.