Safe in our hands

02 Jan 2020

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Read a free article from the latest InPharmacy Winter 2019 magazine.

With patient safety an ever important issue across the NHS, we look at what is being done and the support available for community pharmacies.

The NHS Patient Safety Strategy: Safer culture, safer systems, safer patients was launched in July by NHS England and NHS Improvement. Central to its aim “to continuously improve patient safety” over the next five to ten years, is the creation of a “just culture”, where learning supplants blame. As Dr Aidan Fowler, NHS National Director of Patient Safety, noted in the strategy’s foreword: “Too often in healthcare we have sought to blame individuals, and individuals have not felt safe to admit errors and learn from them or act to prevent recurrence.”

The strategy rests on the twin pillars of a patient safety culture and a patient safety system, each supported by three strategic aims: providing Insight into the nature of safety by drawing intelligence from multiple sources of patient safety information; promoting Involvement in patient safety by equipping patients, staff and partners with appropriate skills and opportunities; and achieving Improvement by delivering effective and sustainable change through well designed and supportive programmes. Properly implemented, the strategy could save almost 1,000 extra lives and £100m in care costs annually from 2023-24.


The new Patient Safety Incident Response Framework (PSIRF) will replace the Serious Incident Framework and support insight generation at the point of care. According to the NPA, patient safety incidents are unintended occurrences that have led to, or could have led to, harm for patients receiving healthcare. Pharmacy teams are encouraged to report incidents, whether harmful or not.


The NHS strategy aims to create patient safety partners (PSPs) who can contribute to safety-related clinical governance committees in NHS organisations by their involvement in service pathway and design, safety governance and strategy and policy. For example, a PSP could be a member of a Medicines Safety Oversight Group.

Another innovation is the establishment of a network of patient safety specialists, key leaders within the safety system: “We want the introduction of the patient safety specialist concept to develop existing people and roles rather than create new posts.” They “will need to work closely with others, including medical device safety officers and medication safety officers…”


Building on the work of the National Patient Safety Collaborative Programme (NPSCP), four national priorities are expected to make a significant impact on patient safety:

  • Preventing deterioration and sepsis
  • Medicines safety
  • Maternal and neonatal safety
  • Adoption and spread of tested interventions.


Dedicated specialist safety programmes include the Medicines Safety Improvement Programme (MSIP), learning disabilities and antimicrobial resistance (AMR) and healthcare-associated infections (HCAIs). With an estimated 237 million medication errors in England, annually ‒ 66 million errors clinically significant ‒ the MSIP aims to reduce medication-related harm, concentrating on high-risk drugs, high-risk situations and vulnerable patients. Case finding in primary care will be enabled “for example, PINCER, a pharmacist-led information technology intervention for reducing clinically important errors in general practice prescribing. This will support work to reduce prescribing error rates by 50%, improving safety and reducing costs”.


Jasmine Shah is the NPA’s Head of Advice and Support Services and Medication Safety Officer (MSO) for independent community pharmacies. Her role includes providing quarterly updates and patient safety incident reports which help share learnings from dispensing errors at a national level (see p.40 for the latest). “The NPA,” says Jasmine, “provides an advice and support service for NPA members – responses to all queries place patient safety as a priority. Also, there’s a dedicated drug and device alert webpage on the NPA website, and the Pharmacy Services team checks the Medicines and Healthcare products Regulatory Agency (MHRA) website more than four times a day to stay on top of all drug/device alerts, medicines/company-led recalls and these are published on the NPA website in a timely way.”

The NPA sends pharmacy-led medicines recalls out as emails in order to ensure appropriate action is taken within specified deadlines. “There’s also,” adds Jasmine, “a dedicated NPA patient safety webpage with links to patient safety resources such as standard operating procedures (SOPs) for incident reporting/valproate dispensing (and much more).”

As MSO, one of Jasmine’s challenges is improving incident reporting functionality: “We’re always looking at new ways to make it easier for NPA members to report incidents and make it a matter of routine when an error takes place. Another challenge is devising ways to improve the analysis and learnings from reported incidents so we can better extrapolate the findings and help make any recommendations easier to digest for pharmacy teams.”


On 30 October the CPPSG and Pharmaceutical Services Negotiating Committee published two new resources providing contractors with supplementary advice and guidance to complete some of the patient safety components of the 2019/2020 Pharmacy Quality Scheme (PQS) in England.

Janice Perkins, who was appointed CPPSG Chair when it was established in 2014, says: “Community pharmacy teams are currently adjusting to a significant change in how they work. Patient safety is a key part of the PQS and these resources will support pharmacy teams to complete the necessary reports and meet the criteria whilst helping streamline their workload.” Jasmine observes that these resources “will help NPA members and others to conduct risk reviews and report patient safety incidents effectively”. Janice tells InPharmacy that the key objectives of the CPPSG are to:

  • Encourage increased reporting and support learning from dispensing incidents and near misses
  • Investigate issues impacting patient safety using audit and data capture programmes, and develop recommendations and share best practice to improve policy or practice sector-wide
  • Understand the culture underpinning safe practice in pharmacies, especially human factors that impact dispensing
  • Learn from other parts of the health system and other industries with expertise in managing safety and risk, such as aviation.


“The great thing about the CPPSG,” says Janice, “is that we’re competitors collaborating to minimise risks to patients’ safety, learning from each other’s expertise.”

As CPPSG Chair, Janice is a key contact point on patient safety with bodies such as the NHS, MHRA and the General Pharmaceutical Council (GPhC): “I’m passionate about the patient safety agenda and the crucial role played by community pharmacy teams in keeping patients safe. Sometimes things go wrong, but no one goes to work intending to make an error or harm a patient or their family. It’s important to report and investigate all incidents, getting to the root cause.

“Once we have that,” Janice adds, “we share the information, so everyone learns. I’d like everyone working in pharmacy teams to be aware of and follow our Report, Learn, Share, Act, Review model, embedding it in professional practice.”

Janice has found in recent months that a substantial part of the CPPSG’s work has been improving patient safety with high-risk medicines like valproate, opioids and look-alike sound-alike (LASA) medications.


One area highlighted by Janice as a challenge is communication, with pharmacy teams receiving large volumes of information daily, and even more so with changes to the pharmacy contract. “The NPA plays a valuable role here,” explains Janice, “as it has great reach to its members.” Janice believes that the pharmacy sector needs to engineer some risks out of the system by using technology “as otherwise human factors will contribute to incidents. There’s also an opportunity to work with schools of pharmacy, ensuring the curriculum reflects patient safety incidents seen in practice. We can all contribute as we interact with pharmacy students and pre-regs to ensure they’re aware of patient safety priorities and key risks”.


Strategies to improve error reporting

Jasmine Shah, the NPA’s Head of Pharmacy Advice and Services, and Medication Safety Officer advises:

  • NPA members can increase staff awareness of the importance of error reporting and pharmacy standard operating procedures for the process. There should also be a “no-fault” culture to ensure that staff members understand that reporting errors they’ve made will, in most cases, not leave them subject to disciplinary measures/ affect their careers; it will improve patient safety as a whole. • Improved staffing levels, particularly during known busy periods of the day, can help ensure staff do not get too busy or forget to record that an error needs to be reported.
  • Regular team meetings (weekly or fortnightly) are important, allowing all staff members to touch base and discuss errors that have occurred within the week/fortnight (as relevant) and ensure all have been reported.
  • Use a near-miss record sheet – this will support staff understanding of the importance of error reporting.


Root cause analysis using five “whys”

By repeatedly asking the question “why?” (use five as a rule of thumb) you can peel away the layers of a problem to get to the root cause. It is a simple tool and can be completed without statistical analysis.

Because it quickly helps identify the source of an issue or problem, you can focus resources in the correct areas and ensure you are tackling the true cause of the problem, not just its symptoms.

Five whys was devised by Toyota as they developed their manufacturing methodologies. It is recommended by NHS Improvement and the Community Pharmacy Patient Safety Group.


A culture of improving patient safety

Janice Perkins says that the key areas that help develop a patient safety culture include:

  1. Involving the whole team – patient safety and incident reporting are everyone’s responsibility
  2. Discussing all incidents to share learning and taking action to prevent reoccurrence
  3. Not assuming. If unsure, ask
  4. Being honest. Everyone makes mistakes so don’t blame anyone
  5. Focussing on recording near misses. This ensures that fewer errors reach patients
  6. Making simple changes to your practice can improve safety e.g. separating LASA drugs on the shelf
  7. Thinking about what might obstruct having a patient safety culture in your pharmacy
  8. Using the 5 Whys technique to understand how an incident happened then you can rectify it
  9. Leading by example. If you don’t report incidents, neither will your team.

Pharmacy staff pressures and patient safety

The CPPSG, explains Janice, considers everything that influences the provision of safe and effective care, including staff health and wellbeing, a priority for community pharmacy owners. Accordingly, the CPPSG has developed guidance to help manage wellbeing in the pharmacy and also suggest remedies when team members feel pressurised. Finally, Janice emphasises that patient safety issues can be flagged up to the CPPSG by emailing