Tools and guidance that will help pharmacists record and review near miss errors to reduce the chance of future mistakes have been published by the Royal Pharmaceutical Society (RPS).
The resources, developed with input from Pharmacy Voice’s Patient Safety Group, aim to support clinical governance in pharmacy and promote an open culture of reporting and learning from errors, the Society says.
Pharmacists can use the redesigned ‘Near miss error log’ to record errors, including the context of where and how these occurred. There is also a guide to using the log and an updated near miss error codes table.
The new ‘Near miss error improvement tool’, which also comes with a guide, helps pharmacy teams to review information from the log and to analyse and identify trends and contributing factors. This can inform the creation of an action plan to prevent future errors.
Tanya Rogers, professional support pharmacist at the RPS, says: “We’ve updated our near-miss resources because we are committed to delivering improvements in pharmacy and patient care. We believe these support tools promote the right culture of learning from mistakes and making improvements so that all pharmacy teams can be involved in the delivery of care for patients.”
Janice Perkins, superintendent at Well pharmacy and chair of Pharmacy Voice’s Patient Safety Group, says:
“Pharmacists are committed to minimising the risks associated with the dispensing process. We know there is a clear link between recording and learning from near misses and implementing changes in professional practice to protect patients. This guidance shares our open approach, which we know is pivotal to advocating and creating a positive patient safety culture.”
The tools have been brought together on a hub webpage on the RPS website at: www.rpharms.com/nearmiss.