The PDA responded to an NHS Improvement consultation on revisions to its Serious Incident Framework (2015). It said it was “encouraged to read the overall approach to patient safety outlined in the consultation document… The focus on systems issues, rather than apportioning blame to the individual for a human error, was not only refreshing but would underpin a safer future for NHS patients.”
An excerpt from the consultation document reads:
Decades of learning in healthcare and other industries has shown that individuals are rarely to blame when things go wrong. It is not true that if people simply try hard enough they will not make errors, or that punishment when they make errors leads to them making fewer of them. The safest organisations and industries recognise that people make mistakes and that the best approach to ensuring safety is to create systems, processes, practices, environments and equipment that support people to do their jobs as safely as possible. This systems approach to safety recognises that incidents are linked to the system in which individuals are working. Looking at what is wrong in the system helps organisations identify and address the root cause of a particular incident and therefore prevent it from happening again.
The PDA outlined how the approach to patient safety taken in its Safer Pharmacies Charter, launched in December 2017, embraces this systems ethos. It also outlined the issues with pharmacy premises regulation in Great Britain which in its view had permitted systemic safety issues to develop and contributed to the need for the charter. The PDA believes there is a need for a greater systems focus on patient safety in community pharmacy.
The PDA said: “The GPhC has stated that the charter reflects its standards for pharmacists and pharmacies. Unfortunately, members tell us that the standards described in the charter are often not met or enforced. Our view is that there are clear shortcomings in pharmacy premises regulation in Great Britain. A Freedom of Information request in November 2017 revealed that the General Pharmaceutical Council (GPhC), which is the statutory pharmacy regulator in Great Britain, has issued over 3,500 sanctions against individual registrants since 2010, but has never issued a single sanction for a failure to comply with its Standards for Registered Pharmacies.”
The PDA’s recommendations included:
- NHS England and NHS Improvement must consider in more detail how the Serious Incident Framework can be applied to community pharmacy practice and GP surgeries. This may involve investigations within those providers in isolation or as part of a wider investigation across different parts of the healthcare system. The PDA explained this may require a field team of investigators dedicated to or focused on pharmacy.
- Since the aim is to embed a systems approach in the Serious Incident Framework whilst not removing accountability, solutions must be found to hold the board members of organisations to account for system failures.
- Patient safety investigation teams must include staff working in patient-facing roles, on the front line of care. They must be able to make recommendations freely, which should be given at least the same priority as those made by management.
- Figure 2 from the consultation document “Summary of common problems associated with investigation in the NHS and the key contributory factors”, should be incorporated in to the Serious Incident Framework to help people recognise the common pitfalls in incident investigation.
Click below to Download the consultation document
