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Community pharmacists in the UK make very few errors when dispensing medicines, with an error rate of between 0.01% and 3.32%, compared with a prescribing error rate of 5% in general practice and 7% in hospitals.
There is a concern that one of the reasons for the low error rate is that pharmacists are not reporting some incidents to the NHS National Reporting and Learning Service (NRLS), which pools data to inform safety initiatives and alerts. Now the 2014–2015 contract between community pharmacies and the NHS in England requires all errors “that did or could have led to patient harm” to be reported to the NRLS, with details of the pharmacy where the incident took place.
Including a pharmacy’s details will help ensure that any anomalies in the data can be properly investigated and it is a step in the right direction.
Rather than being a punitive measure, a commitment to incident reporting supports the culture of transparency and learning that the NHS is seeking to promote.
This should serve as a trigger to expedite necessary changes to the Medicines Act 1968, which currently deems it unlawful for a pharmacist to make a dispensing error. It is unacceptable that the risk of prosecution has not been removed at a time that pharmacists are, quite rightly, being asked to report all errors for the sake of patients.
In 2009, the Crown Prosecution Service prosecuted a pharmacist who made an honest mistake. This threat remains despite repeated reassurances from the Department of Health and government ministers that the law would be changed.
The Rebalancing Medicines Legislation and Pharmacy Regulation Programme Board is drafting proposals to change the law. In a March 2014 statement, the government advisory board said it expected to have finished its work “in time to complete the legislative process during the next Parliamentary session”. The health minister with responsibility for pharmacy, Earl Howe, has acknowledged further delays to the ‘rebalancing’ programme.
Responding to concerns about the new requirement of the community pharmacy contract, the General Pharmaceutical Council said it did not consider a single dispensing error “with no aggravating factors” to be a fitness-to-practise matter.
This may not offer sufficient reassurance for community pharmacists who perceive that naming their pharmacy in an error report could place them at risk of prosecution. The government must make the ‘rebalancing’ work a priority, in line with its ambitions for a blame-free culture within healthcare.
