How does lack of anonymity facilitate shared learning in error reporting?

Concerns about the decision to abolish anonymity for community pharmacies in reporting errors before the decriminalisation of dispensing errors has become a reality

So from April next year, you will have to send the police details of every time you break the speed limit whilst driving, right? And instead of doing this anonymously because you would prefer not to be open to prosecution, you will now have to identify yourself to “allow easier shared learning”1.

This scenario is, of course, not true and arguably misleading but the same logic supports the recently announced change to the new clinical governance requirements of the community pharmacy contract framework. Following amended regulations (presumably from April 2015), NHS England reportedly requires “an increase in the number of patient safety incidents (mistakes) reported by community pharmacies to the National Reporting and Learning Service”2.

We should be relieved that the contract negotiators at least persuaded NHS England not to set minimum targets for errors. Now that would be a perverse incentive. And how does lack of anonymity facilitate shared learning exactly? Much more credible is the other stated reason: “it will help NHS England to identify any pharmacy reporting significantly below expected levels”.

This change is announced before we have seen the legislation proposed to provide defences for pharmacists from the risk of prosecution under the now notorious section 64 of the Medicines Act which proved so controversial in the Elizabeth Lee case. Yes, we are promised by the rebalancing board this is coming soon3. Yes, Earl Howe, Parliamentary Under-Secretary of State for Health, has reiterated his ministerial commitment to implementing these defences at the September Royal Pharmaceutical Society conference. But we have a general election next year and the window for new legislation is narrowing fast.

It is the same sponsor — the Department of Health — that is the negotiator for the contract and the host for the rebalancing board. Was it not possible to make this contractual requirement subject to the implementation of these new defences?

It is reassuring to see this month that the Crown Prosecution Service is following its own guidance with regard to section 64 of the Medicines Act in at least one case and the General Pharmaceutical Council would not normally consider single dispensing errors to be fitness-to-practise matters4. Quite why the proposed defences cannot be promulgated separately from those proposed to change the law affecting owners, superintendents and responsible pharmacists is not clear to me. They are in different parts of the Medicines Act. But this latest announcement seems needlessly to put the contractual cart before the legislative horse.


1. Quotes are from PSNC briefing 015/14 dated September 2014 “Changes to contractual requirements 2014/15”

2. National Reporting and Learning Service which was taken over from the National Patient Safety Agency by NHS England in June 2012.

3. Statement on website of the Rebalancing Medicines Legislation and Professional Regulation Programme

Last updated
The Pharmaceutical Journal, PJ, 22/29 November 2014, Vol 293, No 7837/8;293(7837/8):DOI:10.1211/PJ.2014.20067043

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