New GPhC resources on duty of candour highlight importance of openness when things go wrong

New resources have been published for pharmacists and pharmacy technicians to help them fulfil the duty of candour - the professional responsibility to be open and honest with patients when something goes wrong.

The General Pharmaceutical Council (GPhC) has developed two new resources. Both, the new guide and the toolkit for the pharmacy team, bring together relevant existing policy, standards, and previous statements on the professional obligations of pharmacists and pharmacy technicians, with respect to candour. 

The resources emphasise that the duty of candour is not an add on – it’s a fundamental part of pharmacy professional practice. 

The responsibility to be open and honest applies even in difficult or challenging times and it’s essential that professionals do the right thing for patients, their families and carers. Saying sorry meaningfully when things go wrong is vital for everyone involved. 

Given the link with issues around liability and indemnity, the National Pharmacy Association and the Pharmacists’ Defence Association – as leading providers of professional indemnity - have also contributed to the new resources and highlighted the importance of openness and transparency in this context. 

The additional toolkit for pharmacy teams includes real case studies and examples of notable practice about how pharmacy teams have learned from incidents, to improve patient safety outcomes and minimise the risk of these happening again. All pharmacy teams are urged to use the new toolkit to prompt learning and reflection during pharmacy team meetings or other discussions. Whilst the toolkit examples are drawn from the GPhC’s inspections of community pharmacies, the professional duty to be candid applies in all sectors of pharmacy practice.

Roundtable on duty of candour

Chair of the GPhC, Gisela Abbam, hosted a roundtable meeting on the duty of candour on Monday 13 June, attended by the Chief Pharmaceutical Officers and organisations representing pharmacy professionals, employers and students, patients and the public and other regulators.

Gisela Abbam said: 

“All healthcare professionals have a duty of candour – this is a professional responsibility to be open and honest with patients when something goes wrong with their treatment or care which causes, or has the potential to cause, harm or distress.

“We know that pharmacy professionals are working in multi-disciplinary teams and taking on new clinical roles, and it’s important that they demonstrate the duty of candour in an increasing variety of complex situations.

“At our roundtable, we sought feedback on the new resources. We also discussed further actions that we can all take to make sure everyone working in pharmacy understands their responsibilities to be open and honest when things go wrong, and to improve patient safety.”

Chief Executive of the GPhC, Duncan Rudkin, said:

“Pharmacists and pharmacy technicians, across different settings, work hard to provide person-centred, safe and effective care to patients. But sometimes things go wrong. The way that professionals respond to these situations is key to supporting the people affected and improving patient safety for the future.

“Our new resources highlight the importance of saying sorry. Apologising to a patient does not mean that a professional is admitting legal liability for what has happened. It’s an acknowledgement that something could have gone better, and gives an opportunity for learning to improve patient safety outcomes and minimise the risk of the same thing happening again.”

Speakers at the roundtable welcomed the initiative:

Pharmacist and Patient Voice Champion, Sarah Seddon, said:

“It’s not just about looking forwards to improve overall safety in an abstract way for theoretical patients; it’s about looking after that patient to the best of your ability to restore their trust, to prevent compounded harm and to help them feel safe again. 

“For the healthcare professional good application of duty of candour allows you to know you’ve done your absolute best for that patient and that family. A professional must have the skills, knowledge, self-awareness and humanity to accept what has happened, to own any mistakes and obtain appropriate, timely support for everyone involved.”

Chief Pharmaceutical Officer for England, David Webb, said:

“The duty of candour is an essential part of being a pharmacy professional in the NHS because it is fundamentally important to patients, families, carers and everyone who is involved.

“My experience is that when we take this approach, it is welcomed and engenders further trust and confidence in our professions.

“Finally, it is the way forward in terms of learning from errors and improving our systems so we continuously develop and improve.”

Chair of the Pharmacists’ Defence Association, Mark Koziol, said:

“At the PDA we support the duty of candour and this new initiative by the GPhC.

“Taking a frank and honest approach is crucial, even if it means saying sorry and admitting an error has occurred.”

Head of Advice and Support Services for the National Pharmacy Association, Jasmine Shah, said: 

“We are striving to move away from a blame culture towards a learning culture. It is important to acknowledge when something goes wrong and to help the patient understand what happened. What we aim for is a resolution that is supportive both of the patients and professionals involved.”

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