NPA IN FOCUS NEWS
Janice Oman
Scotland Representation Manager
What quality improvement activities are you planning in your pharmacies for 2018?
The Scottish Government Circular PCA (P)(2017)13 published last November highlighted the importance of ‘the continued implementation of quality improvement activities across the pharmacy team’.
Support in identifying the underlying causes for patient safety incidents will continue to be developed nationally, throughout 2018. The NPA’s online reporting tool enables pharmacists and pharmacy staff to report near- misses and errors in an anonymous, systematic and quick to use format. The Incident Report form is submitted to the NPA without patient or staff identifi ers. After completion, forms can be printed off or emailed to the pharmacy or pharmacy superintendent to keep as a pharmacy record of the incident, where patient details can be added. Records can be kept for auditing purposes.
The Scotland Patient Safety Incident Report has been published every three months for over a year now and can be used as a tool to facilitate patient safety quality improvement discussions with pharmacy teams looking at
their own pharmacy environments. Both the Scottish Patient Safety Incident Report and the English Medicine Safety Offi cer Report provide valuable insight into developing procedures that can minimise near misses, dispensing errors and prescribing errors.
The most recent Scottish patient safety incident report shows the number of reports received has been increasing steadily with 75 per cent of all reports submitted by a pharmacist. Of these pharmacist reporters, one fi fth identifi ed themselves as a superintendent pharmacist, and two fi fths as a locum. Any member of staff can report patient safety incidents with the NPA system. Having more than one personal report of an error can facilitate a more detailed understanding of the underlying causes.
The majority of errors in this period were due to the picking of the wrong drug, at 39 per cent, followed by 33 per cent for picking the wrong dose or strength. Examples of picking errors where one medicine was mistaken with another include: Levothyroxine and Digoxin; Metoprolol and Atorvastatin; Paroxetine and Pantoprazole; Ropinirole and Risperidone; Sumatriptan and Spironolactone; Verapamil MR and Venlafaxine MR. Examples of reported branded errors involving strength were Elantan LA, Epilim and Easyhalers.
The most common contributing factor, at 40 per cent, was medication factors, fi fteen per cent was attributed to work and environment factors and fi ve per cent to education and training factors. The NPA has a full suite of resources to support quality improvement within the pharmacy including the recently launched essential Standard Operating Procedures portfolio.
NPA members can read the full reports on the association’s website. Further information is available from the NPA on 01727 891800 or by email at
pharmacyservices@npa.co.uk.
Please do not hesitate to contact Janice on
j.oman@
npa.co.uk if you have any issues you would like to raise.
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44 - SCOTTISH PHARMACIST
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