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Pharmacy is under-reporting serious prescribing errors, warns NHS England

Community pharmacy could be doing more to safeguard against GP errors and is only reporting one in 46,000 serious mistakes, NHS England senior head of patient safety for safe medication practice and medical devices David Cousins has said

Community pharmacy could be doing more to "safeguard" against prescribing errors with the sector only reporting one in 46,000 serious mistakes, a senior NHS England official has said.

NHS England received just 39 prescribing incident reports from community pharmacists in 2012 out of an estimated 1.8 million serious errors, revealed David Cousins, senior head of patient safety for safe medication practice and medical devices at NHS England.

Although some pharmacists did well in scrutinising prescriptions and acting as a "barrier" to prescribing errors and preventable harms, the sector could make a bigger impact, he told a North East London LPC event last week (April 22).

Pharmacist should better promote and document their role as a "safeguard" against GP prescribing errors, Dr Cousins said.

NHS England received just 39 prescribing incident reports from community pharmacists in 2012 out of an estimated 1.8 million serious errors, it has revealed

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 "I think that community pharmacy doesn't really promote its safety element. It's not well defined, it's not well documented, it's just assumed that it's going on and good things are happening," he said.

A study by the University of Nottingham, commissioned by the General Medical Council and published in 2012, found one in 20 prescriptions contained an error, and one in 550 contained a serious error.

That meant that 1.8 million out of the 1 billion prescriptions GPs write every year contain a serious error, Dr Cousins said.

Pharmacists need not report all errors to NHS England, but they should at least report "some of the incidents", he said.

"There's room for improvement, there's room for learning, both locally and nationally," he said.

Do you think pharmacy should be reporting more?
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Utter rubbish, I'm afraid this is the ridiculous extrapolation of a very questionable research from people who should know better. The cynical side of me thinks that if you write scaremongery stuff you'll get more research money. Oddly, the objective side says.... Erm .....exactly the same. Doubtless there is significant under-reporting as pharmacists have got their hands full sorting the problems rather than filling in forms

john anderson, Locum pharmacist

Several years ago when I was the pharmacy clinical governance with my local PCT ,I along with the GP lead devolped a dispensing/prescribing error reporting scheme. It was a tick box exercise consisting of a double sided sheet of as many potential errors and near misses as we could envisage. The forms were completed anonymously, returned to either myself or the GP lead and every two months we would have a joint GP/Phrmacist meeting to talk through selected errors or potential errors. Every GP surgery and all but one of the local pharmacys signed up ( the exception was a large multiple-a type of footwear- whose official line was that their pharmacists did not make mistakes!) The scheme worked very well until the PCT got worried that it might it might receive bad publicity if the press got hold of information of the types of errors being reported and withdrew the funding. The exercise did show that there was a willingness on the part of both GPs and Pharmacists to discuss their errors but unfortunately the PCT was more interested in supressing rather than learning from the information that was produced. It would be nice to think that attitudes may have changed today ,perhaps when pigs fly!

Hemant Patel, Community pharmacist

Dr Cousins tone and presentation was to encourage pharmacists to create a role for themselves so that they have future in the NHS. I thought he was very community pharmacy friendly and was genuinely saying that as the last check in the system they could do better.

I personally feel that pharmacists have a role to improve health by reducing drug related problems that at present lead to 1:6 hospital admission and 50% of LTCs patients not being compliant with their prescribed medicines.

If the ostriches in community pharmacy want to look up their backsides they can. But, they cannot complain when Amazon type delivery system impacts on their core business and PDA members start providing quality improvement and safety services from surgeries and in patients homes.

Dr Cousins was alerting community pharmacists to an opportunity to improve business and professional standing. Instead people are reacting in a defensive way. Improving patient safety is a serious business opportunity that NEL pharmacists will be taking with enthusiasm. Others can stick to shifting boxes from wholesaler to the patient. Just think: if doctors did not make clinically significant mistakes, what role would pharmacists have that cannot be done by a technician or a robot?

Wake up. Box-shifters have at most 18months to change or be replaced by a more efficient distribution system. The outcomes that the government and the profession want is clinically significant outcomes. Box shifting does not improve clinical or financial outcomes; it increases costs due to iatrogenic diseases. So, box shifters are a problem and not a solution for the future.

We will work with Dr Cpusins and others to make NEL the safest place in GB to take prescribed medicines. Already an average NEL pharmacy earns more per pharmacy from enhanced services than any other area. Soon they will be earning more from clinical services than any other.

GPs make 1.8 million serious errors. Not pharmacists. But, 1.8 million errors appear in the community; so with community pharmacy paid to be the last check in the system who has to improve? Want more money for shifting boxes? You haven't chance in a thousand million.

Instead of taking offence, try becoming a solution to a problem and you might then just have a future for another five years or so.

Amal England, Public Relations

If you are the same Hemant Patel that was a previous president of the failed RPSGB, then I would like to ask you what happened to professionalism and opportunities for pharmacy when you were president? Your tenure was probably the worst in the history of the profession. I hope you have changed and are doing something meaningful for the profession- you are indebted.

John Alan James Robinson, Superintendent Pharmacist

Pharmacists have a role. Dispensing safely. And yes they are the final check in the chain. I have no problems with that. Needs to be funded though as does all manner of services that just might come our way. Ostriches who are not contractors or who were and may have forgotten the daily stresses and strains should ponder longer. Duty of candour and offences which will apply to all health professionals will see cases in the courts. Dirty washing in public is all well and good but does it lead to more confidence in a profession in the eyes of the public ? We can all learn lessons from errors and reporting . Risk management is appearing large in the standards for pharmacists. What about dispensing doctors. Little did I realise that 1984 and Aldous Huxley would happen so fast.

N O, Pharmaceutical Adviser

"Dr Cousins was alerting community pharmacists to an opportunity to improve business and professional standing."

How on earth do use propose we would be able to improve business by pointing fingers at the prescriber in a community set-up ?

Professional standing -- by spending more time folowing up on the silly mistakes done by a highly qualified (un)professional GP ? where would the extra funding come from ? to do these on a regular basis?

I personally thought Hemant always faught in favor of Pharmacists. But, I must admit, in the name of getting more professional recognition (which is well overdue ) you are not really making any great difference. For me, this is one more ploy to demean our profession and reduce funding.

Anyway, the amazon style delivery will happen if it has to happen. Only thing that will not happen is the so called pharmacy leaders fighting tooth and nail to prevent such things from happening and fight to get more compensation for what is already happening in community pharmacy before asking for more work (with a good remuneration attached) I know this will never happen, sorry to be negative but it is already happening.

Kevin Western, Community pharmacist

I take on board at least some of what you are saying but I "report" the errors I spot to the surgery concerned (forget talking to a GP) surely they have a duty to report to nhs england? I report the errors I make, why am I expected to do their work (again). we are drowning in a sea of things we have to record or report, most of which make no difference to any outcome but satisfy somenes craving for statistical proofs. By all means push for more scrutiny of rxs , better access to GPS to discuss errors, more involvement in prescribing and clinical services , but yet another form or reporting page on the net to fill in - no thanks

Mat Patel, Community pharmacist

By the time we have reported all these 1.8 million seroius errors, if the the GMC practices a scrict code of conduct for 'Fitness to Practice' (like our GPhC), I doubt there will be any prescribing doctors left in England.

Maybe this is an improtant time for budding pharmacists to become independent prescribers, which will allow pharmacy to demonstrate its important role in the NHS framework and really safeguard against prescribing errors...

The time is now right for us to step into the prescribing role and scrub out these unecessary prescribing errors...

Hemant Patel, Community pharmacist

Yes, yes, yes. Let us get the Mickey Mouse MURs right first before we fall over with nappies around our ankles! Merchants need to put the Drug Tarriff and wholesaler price list on one side and instead pick up the BNF for a while first. I think we should dream big but not loose the touch on the ground.

N O, Pharmaceutical Adviser

"Box movers" ??? to "telephone operators/ tele medicine reps" is that what you want us to be Hemant ?

Unless we move those boxes we wont be able to serve the patients with their meds !! isn't it? People sitting in rooms in front of computers with loads of data at hand (of no use) can always make comments but face it and work at a pharmacy in current situation with less supporting staff, constant calls from Head Office to achieve targets, constant patient queries over the counter, loads of methadone dispensing and on top loads of scripts to do. Then you will know where the nappies are (if you get some time to think about it)

John Alan James Robinson, Superintendent Pharmacist

It might be useful to know how many adverse reactions can be shown to have actually occurred. PMR systems report serious interactions on a daily basis and on every occasion
for particular patients. Much polypharmacy starts in secondary care.Warfarin is mentioned in the report. Blood tests and warfarin cards are relied on . MDU is usual on the prescription. This is rated as a potentially serious error. Can these potential errors be translated into serious events? i dont know. But the safety agencies need a reason for their existence as do some academics. Of course safety is paramount but i do wonder about scaremongering. Its coming though. Daily incident reporting . Working with professionals and whistleblowing is a sign of the times. Yet pharmacy is remarkably safe. In fact the only incident the GMC refer to is A N OTHER and peppermint water.

Uma Patel, Community pharmacist

Come down to the real world Mr Cousins.
Turkeys do not vote for christmas.
Does he report to the Police every time he drives at 31 mph? Of course he does not, or is he a model citizen who never goes over the limit.
With a potential criminal charge why would one report anything.

Farmer Cyst, Community pharmacist

Even a dog knows not to bite the hand that feeds it.

Paul Miyagi, Information Technology

Its that subservient attitude that has put pharmacy in the place it is today! Stand up and be counted . You too are a professional !!


That's a bit rough ruff ruff...

N O, Pharmaceutical Adviser

Another way of putting more pressure on Pharmacists.

Just read " estimated 1.8 million serious errors"

If, based on these figures, the pharmacists are being blamed, then what actions or any necessary steps have been taken against GPs who seem to care a damn in first place.

It is completely un-acceptable to blame pharmacists without correcting or at least having a system to correct in place at the root.

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