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Multiples urged to step up reporting of medication errors

Practice A superintendent would be responsible for overseeing the reporting of medication errors to help improve patient safety, says NHS England and MHRA

The government is calling on the multiples to appoint leaders to oversee the reporting of medication errors as part of a "step change" in improving patient safety.

Multiples should appoint a superintendent who would be responsible for overseeing the reporting of medication errors from September in England and Wales, NHS England and the MHRA said in a patient safety alert issued last week (March 20).

They should also nominate a medication safety officer (MSO) to join the newly established National Medication Safety Network and the National Devices Safety Network, which aim to improve communication and feedback on reporting safety issues across the NHS.

The appointed MSO would act as the main contact for NHS England and MHRA as well as identify an existing or new multi-professional group to review incident reports and act locally to improve medication and device safety.

A superintendent would be responsible for overseeing the reporting of medication errors to help improve patient safety, says NHS England and MHRA

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The alert also called for community pharmacies to continue to report medication errors to the National Reporting and Learning System (NRLS), report device errors to the MHRA's online system and "take action" to improve reporting locally.

The alert was in response to a "number of strategic drivers," the MHRA said, and followed a 20-day consultation in November last year.

The Francis report into the hospital failings at Mid Staffordshire hospital and the inquiry into the medicine watchdog's handling of the PIP breast implant scandal had recommended "taking steps to maximise the quality and quantity of adverse incident reports from healthcare organisations", it said.

NHS England's director of patient safety Mike Durkin said the move towards improving the reporting of medication errors was a "step change" in the government's approach to patient safety.

The MSOs and newly formed networks would "enormously increase" NHS England's ability to improve safety by "broadening" their reach and establishing channels for sharing and feedback.

The MHRA's director of vigilance and risk management of medicines June Raine said the move would "strengthen the reporting and learning" from medication errors and device incidents.

NHS England was working in collaboration with the pharmaceutical and devices industry through the Association of British Pharmaceutical Industry and the Association of British Healthcare Industries, it said.

Do you think the plans will improve patient safety ?
We want to hear your views, but please express them in the spirit of a constructive, professional debate. For more information about what this means, please click here to see our community principles and information

Leon The Apothecary, Student

There needs to be a confidence in the system to facilitate error reporting and near misses. My fear is that internally, until it reaches a severe situation, change will not happen. Being able to address risks early should be a primary target with these plans and follow through with real improvements to prevent them happening again.

Unfortunately, mistakes and errors can and do occur. Moving away from the criminalizing blame game and towards improving and addressing issues is the only logical way forwards in my eyes.

Brian Austen, Senior Management

The only way to ensure errors are reported is to allow patients to easily inform an independent monitor of their complaint against Pharmacy, GP Practice, Hospital, etc. That monitor can then ensure that all complaints brought to their notice by patients are properly investigated and if necessary, remedial action taken. This will give patients the confidence to make complaints. Until that happens mistakes and errors will continue to be hidden. Even those currently responsible for monitoring errors try to play down how the amount of errors that are happening because it shows that error reporting and complaints procedures are not fit for purpose.

London Locum, Locum pharmacist

Reporting multiple errors/near misses at a multiple would akin to building a prosecution against yourself when you get the inevitable disciplinary leading to dismissal. The fact that you had no support from senior managers and reduced/non-existent dispensary staff would be quietly skipped over.

London Locum, Locum pharmacist

I think the multiple will do what they want when they want

Nick Hunter, Community pharmacist

Surely the precursor comment to this is that the Government have got to decriminalise one off dispensing errors?
Also - NHSE and MHRA need to put in a mechanism with the NRLS to feedback incidents reported to local teams so learning can be acted on to improve patient care. Currently there is no feed from the NRLS back to local organisations and reporting is dependent on double reporting - in an environment of cutbacks and work pressure realistically this is never going to work

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