The Patient Safety Group has launched a number of incident reporting principles in their most recent Patient Safety Bulletin. The group, established by Pharmacy Voice, has agreed upon this set of core reporting principles from the results of their anonymous survey into incident reporting and safety culture. This continues the Patient Safety Group’s great work in the area of patient safety, sharing and promoting best practice.
These core reporting principles form one piece of work the community pharmacy Medication Safety Officers (MSOs) of the group have carried out. The MSOs carry out this work to fulfil their duty to ensure increased reporting and improved learning from incidents across their own organisations and the pharmacies they represent. The group is determined to build on this base and continue its focus on improving the reporting of incidents and encouraging culture change across the pharmacy sector. The principles have also been shared and discussed with the Royal Pharmaceutical Society for consideration when developing professional standards for error reporting.
The group has put together a helpful Report, Learn, Share, Act and Review wheel to reinforce their principles and their recommended patient safety incident reporting process. The process involves: reporting of all errors and near misses, involving the whole team, identifying and investigating causes of errors and using them as learning opportunities, discussing these causes with others, promoting learning, and making and reviewing changes to practice.
The survey, also included in the bulletin, provides insight into how patient safety culture and practice are perceived by community pharmacy teams. Reporting and learning processes within pharmacies and the barriers to reporting were the primary focus of the survey. Time constraints were found to be the most significant barrier to reporting, with the threat of criminal sanction not far behind, and 3 in 10 respondents felt that there was a lack of helpful feedback and learning from reporting incidents. The survey also identified that simpler reporting tools/systems would encourage teams to report a greater number of patient safety incidents. Other barriers to reporting include a lack of training in reporting and a lack of clarity in reporting procedures.
Dedicated to overcoming the issues that arose in the survey, the Patient Safety Group will also be working on their Rebalancing Programme. This programme is designed to create a criminal defence to inadvertent dispensing errors, which they hope will significantly increase the amount of incident reporting and learning, leading back to the sharing of best practices.
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