Living up to expectations

13 December 2017

It is rare to see agreement across all of the political parties, particularly in the current climate, but that is exactly what we saw when the Dispensing Errors (Registered Pharmacies) Order was debated in the House of Commons and House of Lords recently.

It was passed unanimously by MPs, and it was recognised in both Houses that this important change should make a real difference to patient safety, by encouraging reporting of and learning from dispensing errors that occur in registered pharmacies. The parliamentarians speaking in the debates highlighted their confidence that, in response to this change, pharmacy professionals would be more likely to report and learn from dispensing errors in registered pharmacies.

As an organisation, we have advocated for this change for a number of years, and are delighted that the long-awaited legislation to introduce a defence for inadvertent dispensing errors that take place in registered pharmacies has now been approved by Parliament. This change in legislation will remove a barrier to improved reporting and learning from errors and will therefore be beneficial for patient safety. It is also the right thing to do, in fairness to pharmacists and pharmacy technicians, who do so much to  maintain and improve patient safety.

The legislation is now expected to come into effect next year, once the final legislative process is complete. We know it has been a very long wait to get to this point, and we recognise the importance of this change for all pharmacists and pharmacy technicians.

And this includes those working in settings other than registered pharmacies. We understand the government will consult next year on removing the threat of criminal sanctions for dispensing errors made by pharmacists and pharmacy technicians working in settings other than registered pharmacies- and we will continue to urge for this to move forward at the earliest possible opportunity.

While we wait for the law to change, we think there is an opportunity for all of us to focus our attention on what more we can do to learn from errors, to reduce the probability of them happening, and to improve the care people receive.

We know that, thanks to the significant efforts of pharmacists and pharmacy technicians across Great Britain every day, the number of dispensing errors is very small when considered against the number of items dispensed each year.  As Don Berwick, the leading authority on patient safety, said recently in an interview with the PJ; ‘Pharmacy dispensing is safe compared with other areas of healthcare’. 

But we know there is more we can all do to reduce the number of dispensing errors even further, and to make sure that when they happen, we’re all doing everything we can to prevent them happening again. 

We know there are already a number of local and national initiatives across England, Scotland and Wales to reporting and learning, which are making a difference. These include the Community Pharmacy Patient Safety Group, which is driving reporting culture and practice across community pharmacy in England, and sharing learning from patient safety incidents through its networks. In Scotland, the Quality Improvement in Pharmacy Practice Collaborative has brought together key organisations including HIS, RPS, NES , CPS, NHS Boards and the Alliance to help embed continuous quality improvement in pharmacy services and share learning across Scotland. And in Wales, the Error Reporting Task and Finish Group has been working to improve error reporting and promote an open culture within pharmacy, by simplifying and raising awareness of the reporting system, and working with employers and stakeholders to promote reporting and share learning. 

But there’s more we can all do- including the GPhC. We all have to live up to the expectations expressed in the parliamentary debates that this change in the law will make a real difference in reporting and learning.

For our part, we will be considering how we can better use and share the information we receive about dispensing errors to support learning, reduce risks and improve patient outcomes.

And we would encourage each of you to reflect on how to live up to the expectations of openness and honesty set out in the standards for pharmacy professionals whenever errors occur.

We recognise that the possibility of action by the regulator can also deter people from reporting errors- and so I want to emphasise again that single dispensing errors would not in our view constitute a fitness to practise concern, unless there were aggravating factors. 

One of our inspectors, Colette, sums up our approach in the ‘focus on’ article about dispensing errors; “my main concerns when investigating a dispensing error are firstly to try to find out how the error may have happened, and secondly to understand what learning points or preventative actions have been taken (or are needed) to avoid a similar event happening again.”

I know that it is never easy to admit a mistake, but to err is human, and we, like you, want to learn from each error, for the benefit of patients and the public.