QPS Patient Safety Report


Written safety report at premises level available for inspection at review point, covering analysis of incidents and incident patterns (taken from an ongoing log), evidence of sharing learning locally and nationally, and actions taken in response to national patient safety alerts.

20 points for achieving the criterion; can be claimed once in April OR November 2017.

The written safety report should be specific to each individual pharmacy and should be a summary that reflects the events taking place in that pharmacy. Contractors are encouraged to work with other pharmacies to share their learning.

Aim/Rationale

The aim of this criterion is to foster a culture of learning and continuous improvement in every pharmacy with regard to patient safety. It is based on the following principles that have been developed in collaboration with community pharmacy Medication Safety Officers (MSOs) and stakeholders to support the production of the written patient safety report. These are complementary to the principles of incident reporting which can be found here.

1. Incidents to be considered in the report should include errors or near misses that involve medication that have caused patient harm or had the potential to do so. Errors picked up early in the dispensing process or documentation errors would therefore not be included.
2. The aim of a pharmacy written patient-safety report is to recognise and support development of a safety culture. In particular, the report should demonstrate continuous improvement through reviewing and reflecting on errors.
3. Where errors occur, a proportional response to changes and safety measures should be taken. Contractors should take care that in focusing on one area for improvement, they are not neglecting others.
4. Where human intervention is involved, the potential for error exists. Using systems and processes to support staff to make the correct decision or take the right action improves safety. Care should be taken in developing these processes so that they are user friendly, otherwise they risk not being followed correctly, increasing the risk of error.
5. The best barriers to error are the simplest and often rely on physical measures.
Error occurs when a complex set of circumstances converge and make it possible. Understanding the relationships between circumstances requires the gathering of information, followed by analysis and reflection. This is why it is important that contractors review errors and share their learning.

Community pharmacies are already required to record patient safety incidents in an incident log. Reporting these to the National Reporting and Learning Service (NRLS) is a professional responsibility as described in the Professional standards for the reporting, learning, sharing, taking action and review of incidents. Contractors can report these using an e-form (available here) or use other systems that meet the required standards.
 
Reporting

In order to meet this quality criterion, contractors should:

  • collate incidents and near misses from an ongoing log
  • analyse these and look for patterns
  • reflect on the learning from these
  • take actions to minimise future risk from repeated errors
  • share their learning (both locally and nationally).

This should then be documented in a written patient safety report.  The report must also include evidence of specific actions taken by the pharmacy in response to local errors and national patient safety alerts issued by the Central Alerting System

You can find out more about Patient Safety Alerts on the NHS England and NHS Improvement websites.

Contractors may wish to use the template in Annex 1 of the NHSE guidelines issued in Feb 2017 to collate and review patient safety incidents each month. Contractors can then use the outputs of these forms to complete their annual written patient safety report. Annex 2 from the NHSE document provides a template to create this report for contractors to use should they choose. The report does not need to be routinely submitted to NHS England but contractors should ensure that a copy of the report is kept in the pharmacy.

There are a number of different ways that contractors can share learning locally. This might take the form of a meeting with local general practices to share learning from incidents or near misses, sharing learning with other local pharmacies, a Local Pharmaceutical Committee (LPC), Local Professional Network (LPN) or Local Practice Forum (LPF) event, or sharing via a newsletter.

Further support for individual community pharmacies to meet this quality criterion will be made available via NHS Improvement through the network of community pharmacy MSOs.

Contractors will be required to declare via the NHS BSA online declaration page that they meet this criterion.