Effective use of monitoring and review mechanisms and a culture of learning from incidents.

Pharmacy type

Community

Pharmacy context

This is a community pharmacy based on a main road open 9am to 7pm on Monday to Friday and 9am-12pm on Saturday. The team dispenses in the region of 9,500 NHS items, a small quantity of private prescriptions per month and offers a range of services including both private and NHS influenza vaccinations, medicines use reviews (MURs), new medicines service (NMS) and Monitored Dosage Systems (MDS) to approximately 100 patients. The pharmacy also supplies Methadone on a supervised, and an unsupervised basis. Services are provided to a varied and predominantly elderly population with a range of chronic health care needs.

Relevant standards

• 1.1 - The risks associated with providing pharmacy services are identified and managed
• 1.2 - The safety and quality of pharmacy services are regularly reviewed and monitored

Why this is notable practice

Dispensing accuracy is constantly monitored and reviewed and there is a robust system in place to deal with, discuss and improve practice following incidents. There is evidence that the pharmacy team seek to identify, manage and minimise risks with trends being analysed.

How the pharmacy did this

Near misses were identified by the pharmacist and discussed with the member of staff responsible for the error as soon as it was identified. Feedback was given and both the pharmacist and the member of staff would discuss ways to minimise any further instances. Details of the near miss were entered by the dispenser into a paper form near miss log. Details included the time and date of the error, identification of staff involved and the action taken to prevent recurrence. A staff member was nominated at the end of the month to analyse trends in near misses and was then required to discuss any trends in staff meeting. Outcomes of the meetings were documented and signed by all staff. A recent patient safety incident involved the incorrect supply of Latanoprost eye drops in place of Chloramphenicol. A “critical incident meeting” was held involving all staff. The incident was discussed and ways to prevent recurrence were analysed. Previously eye drops were stored together in a section of the fridge, however the team decided to segregate them to reduce selection errors. In addition to this, a procedure was introduced to ensure dispensing labels were affixed to eye drop bottles rather than on the box.

What difference this made to patients

The involvement of all staff in analysing errors and determining the response to critical incidents, improves ownership of changes required to improve patient safety.