The Patient Safety Group provides a forum for members to share and learn from each other, this includes when incidents occur.
We believe all pharmacy teams should embed the Report, Learn, Share, Act, Review principles in their everyday procedures, and we encourage them to make use of the template below when an incident occurs.
Download Report, Learn, Share, Act, and Review principles template
The example below shows how the Report, Learn, Share, Act, and Review principles can be implemented.
Isotretinoin is used to treat acne. When taken during pregnancy it can cause birth defects and miscarriages.
The MHRA advises that patients of childbearing potential being treated with isotretinoin must be on a Pregnancy Prevention Programme with regular follow-ups and pregnancy testing. Each prescription for oral isotretinoin should be limited to a supply of up to 30 days’ treatment.
Following an incident in which a patient of childbearing potential appeared to have been issued a 4-month prescription of isotretinoin instead of the intended 4 weeks the Group developed a resource to share what happened, enabling others to learn from the incident and review their own practices.
For more information on the use of isotretinoin and the importance of pregnancy prevention see MHRA guidance on Isotretinoin for severe acne and RPS’s guidance to dispensing oral isotretinoin and pregnancy prevention.