No-blame culture should be fostered in pharmacy

Even though the requirement to name a community pharmacy in patient safety reports has been postponed, the sector must do more to improve the reporting of dispensing errors.

“To those waiting with bated breath for that favourite media catchphrase, the ‘U-turn’, I have only one thing to say: ‘You turn if you want to. The lady’s not for turning’.” In one of her most famous quotes, Margaret Thatcher told the Conservative Party Conference of 1980 that she would be sticking to the course of economic reforms that had been set.

However you feel about Thatcher’s decisions in her time as UK Prime Minister, she most certainly stuck by them. Yet sometimes digging in one’s heels is not the best approach. Sometimes it helps to listen. And then to change your mind.

Community pharmacists in England will welcome the news that the contractual requirement to name their pharmacy in incident reports has been postponed. Although not quite a U-turn, it is clear that someone has had a rethink and the delay is reassuring.

NHS England and the Pharmaceutical Services Negotiating Committee had agreed in September 2014 that all errors that caused or could have led to patient harm must be reported to the NHS National Reporting and Learning Service (NRLS) along with the details of the pharmacy involved. The timing of the decision was criticised widely, including on these pages.

The problem was that the Medicines Act 1968 still deems it unlawful for a pharmacist to make an accidental dispensing error, despite efforts to have the legislation reformed. It seemed unacceptable to have the threat of prosecution still in place while asking pharmacists to boost incident reporting for the benefit of patients.

The Rebalancing Medicines Legislation and Pharmacy Regulation Programme Board has been drafting proposals to have the law changed. And there have been repeated setbacks.

The fact that the enhanced incident reporting requirements are now delayed until early 2016 would indicate that the “rebalancing” work is due to be delivered in the coming 12 months.

Community pharmacists should not view this development as an excuse to hold back on reporting patient safety incidents.

Event reporting is low. Of the over 1.5 million events in England and Wales reported to the NRLS from April 2013 to March 2014, 15,196 were from community pharmacy — just over one report per pharmacy per year. And a closer look at the figures reveals why NHS England is so keen to obtain pharmacy-level data: of the incidents reported, 1,785 were attributed to England and 260 to Wales, meaning that the vast majority of reports (13,151) have no geographic details specified. This hampers its ability to analyse trends in incident data and take appropriate action to support patient safety.

We support the commissioning board’s moves to improve transparency around reporting. What is needed now is a speedy resolution of the threat of prosecution that pharmacists face in practice, which seriously undermines the no-blame culture required for healthcare professionals to learn from their mistakes.

Last updated
The Pharmaceutical Journal, PJ, 31 January 2015, Vol 294, No 7847;294(7847):DOI:10.1211/PJ.2015.20067706

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