Peer discussion example: a locum’s view on medicine safety and near misses

Peer discussion.

As the General Pharmaceutical Council’s (GPhC’s) revalidation deadline (31 October 2019) approaches, many pharmacists entering their second cycle of revalidation will be recording their learning and considering how to complete their peer discussion.

The following example peer discussion entry is intended to act as a guide to better enable you to complete your own learning record for submission to the myGPhC site. You should not replicate or copy and paste this material, rather create your own entry based on your experience. You should reflect on your own practice and consider how your patients or service users have benefited from your learning.


Reflecting on near misses as a locum

Please give the name of your peer on this occasion

N.E. Pharmacist

Please give the role of your peer on this occasion

Locum pharmacist

Please give the organisation of your peer on this occasion

Locums inc.

Please give the telephone number of your peer on this occasion

01234 567890

Please give the email address of your peer on this occasion

Describe how this peer discussion changed your practice for the benefit of the people using your services.

Tell us why you chose this peer.

Tell us how this peer discussion has helped you to reflect on and make improvements to your practice.

Give a real example of any beneficial outcomes for the people using your services as a result of making changes to your practice.

Do include any feedback about your practice that you have had from other people.

You do not have to include information on the subject(s) discussed if you feel the contents are confidential.

I chose a locum pharmacist to be my peer. I chose this peer because they work in a similar environment to me and, therefore, have similar experiences in their day-to-day work.

The focus of my peer discussion was to consider how to avoid errors and near misses in the community pharmacies where I work. We discussed issues that can lead to errors, focusing on work space, best use of pharmacy staff and how a busy pharmacy/workload can have an impact.

After talking about what issues arise, we discussed strategies could help minimise errors and near misses in practice and ensure the safe running of the pharmacy. Through my peer discussion I realised that although I work to prevent errors on a day-to-day basis as I locum in a pharmacy, this does not result in a change of practice within the pharmacy itself. During the discussion we both agreed that there is a need to share our learning when it comes to safe pharmacy practice with the pharmacy team. My peer explained how they have previously left detailed notes of issues they encountered and received positive feedback from managers on this. Although I would leave notes after a shift, it tended to be hand over notes detailing issues from the day, but not necessarily suggestions for improvements related to patient safety.

My discussion helped me feel empowered to try to make changes on a wider scale. Therefore, now when I complete a shift, or a period of locum employment in a pharmacy, I contact the manager or area manager by email (or via a phone call if email is not available) and briefly go over the issues I encountered while I was there and how I would make changes to avoid these in the future. I explain that my recommendations typically come from good practice I have observed elsewhere in community pharmacy. Often the manager or area manager will thank me for the information, but because I locum, I am not always able to see whether my advice was taken on board and implemented.

However, in one instance, on returning to a pharmacy where I had previously completed a locum shift and provided feedback to the manager, I found that they had changed part of their dispensing practice based on my recommendations. Feedback from the pharmacy staff was that they welcomed the change as it resulted in fewer near-misses related to the given issue and that patients are less likely to suffer harm as a result. I continue to provide feedback to pharmacy teams when I locum in a new pharmacy.

If you are creating your peer discussion, see ‘Revalidation: how to complete a peer discussion record’, which provides a step-by-step guide for pharmacists and pharmacy technicians writing and submitting this vital part of revalidation.

You may also find the following articles related to medicines safety and useful:

How the Royal Pharmaceutical Society is supporting members with revalidation

A dedicated revalidation support hub, which also provides more information on the various support services offered is available on the Royal Pharmaceutical Society (RPS) website and includes:

  • RPS MyCPD app – An app supported by The Pharmaceutical Journal. Available for iOS devices via the App Store and Android devices via Google Play. For information on how to use the app, see ’How to use the new ‘RPS MyCPD’ app for pharmacy revalidation
  • Revalidation support service – Members can contact this service by phone (0333 733 2570 Monday to Friday 9:00 to 17:00) or email
  • Revalidation events – information on the latest events can be found on the website.
  • MyCPD Portfolio – members can create a portfolio allowing you to make records of any CPD you have engaged with and retain these records throughout your career.


Last updated
The Pharmaceutical Journal, Peer discussion example: a locum's view on medicine safety and near misses;Online:DOI:10.1211/PJ.2019.20207138

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