In September 2014, NHS England (now NHS Improvement) and the MHRA issued a Stage Three Directive recommending all large community pharmacy organisations (as well as NHS Trusts, homecare companies and independent providers) to identify a named Medication Safety Officer (MSO) to review medication incidents and oversee safety improvement within their organisation.
Most of these MSOs in community pharmacy organisations are the Superintendent Pharmacist, or a senior member of their team, and are also the point of contact for safety for their pharmacy teams located outside of England. An individual MSO was also appointed at the National Pharmacy Association (NPA) to support all pharmacies with fewer than 50 branches, ensuring the whole sector was covered.
The newly appointed community pharmacy MSOs united in their commitment to advancing patient safety culture and practice across community pharmacy.
In February 2015, with the facilitation support of Pharmacy Voice, the MSOs established a self-funded Patient Safety Group to regularly meet and openly share and learn from each other, as well as from other safety conscious industries, consider how this learning could be applied across the pharmacy network, then work together to create the opportunities to do so.
The Group, chaired by Janice Perkins, Pharmacy Superintendent at Well, has worked closely, and will continue to work closely, with NHS Improvement to improve the mechanisms by which patient safety incident data is captured and fed into the NHS National Reporting and Learning System (NRLS) database, and an NHS Improvement representative is present at our bi-monthly meetings.
In order to drive the sector-wide agenda for patient safety improvement, we agreed a detailed and ambitious work programme of specific initiatives over the last two years. Over this period the Group have learnt from one another to apply evidence-based practice to reduce the likelihood of errors occurring in one pharmacy being replicated across other parts of the network.
Sector-wide work plan
The ambitious work programme of the PSG has been an innovative whole-sector yet entirely self-funded approach to improvement. The key objectives have been:
- To encourage increased reporting and support the application of learning from dispensing incidents and near-misses;
- To investigate issues impacting on patient safety using programmes of audit and data capture, and to develop recommendations and share best practice to improve policy or practice across the sector;
- To understand the culture that underpins safe practice in pharmacies and, in particular, the human factors impacting the dispensing process;
- To learn from other parts of the health system as well as other industries with expertise in managing safety and risk, e.g. the aviation industry.
Each individual MSO, and their employer, has committed to helping spread outputs throughout the sector and when setting out the plan, MSOs volunteered to take the lead on specific initiatives where they already had expertise or a personal interest.
As an example, two MSOs shadowed their delivery drivers for a day, to get a better understanding of the potential risks that can arise when delivering medicines to vulnerable patients in their homes. Another MSO led our work on safeguarding vulnerable people, securing Level 3 Safeguarding training for the entire Group and drafting an informative briefing and exemplar company procedure which other MSOs could use to embed safeguarding policies within their own organisations.
Over the last two years, the community pharmacy MSOs have disseminated resources and learning across the entire community pharmacy sector through both the NPA to independent pharmacies and through the larger pharmacy companies to their individual branches with the aim of increasing engagement and embedding patient safety into everyday conversations.
Individual MSOs communicate with their pharmacy teams through a number of different channels and most use regular reports, letters or downloads to share data and best practice relating to patient safety. The MSOs from both large and smaller multiple pharmacies have dedicated real-time dashboards which can be used at both central office-level and individual branch-level to monitor trends in incidents. They also can use these systems to identify any very low or non-reporters who may need support.
Sharing and Learning
Alongside each MSO sharing learning from serious or common incidents across their company’s branches or across the independent sector, the most powerful learning and insight into potential practice changes has come from incident details being shared at the regular ‘Share and Learn’ slots on every PSG meeting agenda.
As some of the more recent examples, the PSG has looked at incidents involving liquid preparation calculations, drugs implicated in common errors, ‘lookalike soundalike (LASA)’ drugs and medicines for children.
Once the details of an incident have been shared, raising awareness amongst the other MSOs, the PSG will discuss any different procedures or practices which could minimise the risk of these incidents occurring. These changes can range from introducing ‘CHILD’ stamps for paediatric prescriptions to creating Tallman lettered ‘shelf-edgers’ to rearranging the way some medicines are organised in the dispensary e.g. moving high-risk medicines to “Z”.
Helpful resources have been created or shared during these sessions, which have then been tweaked, branded and re-disseminated across different pharmacy organisations and pharmacies to create consistent messages. Some of these are available on our Resource Hub.
We recognise that it will never be possible to completely eliminate patient safety incidents and have instead focussed efforts on changing safety culture, increasing the quality of incident reports and reducing levels of harm caused. Many MSOs are able to report an overall decline in the number of incidents resulting in serious harm, especially involving the medications we have issued ‘Top Tips’ resources on or discussed specifically at the bi-monthly PSG meetings.
Improvements in quality across the community pharmacy network will, by definition, have a knock-on positive impact on patients. However, these also result in increased value for pharmacy team members themselves, whereby breaking down barriers and improving organisational culture has resulted in them feeling more confident to be open and honest, raise concerns and take an active role in offering suggestions for practice changes.
We are committed to improvement and already have lots planned for the next few months so keep an eye on this site for regular updates or use the ‘Contact’ page to join our mailing list.