Medicines safety – everyone’s business

A recent conversation through @wepharmacists on twitter has me thinking about medicines safety.  I can almost hear leaders across the board saying – it’s everyone’s business. The usual management rubbish when they can’t think of anything better to say.

i don’t really want to comment on hospital pharmacy – the chief pharmacist is responsible and through the board, has oversight of the whole process from admission and prescribing, through procurement and supply to administration and discharge. The whole 9 yards! Post Francis, I am sure that every Chief Pharmacist will fill any of the gaps in their organisations process.

But what about primary care?

I remember a day working in community pharmacy when a grateful patient thanked me for spotting an error and saving their life. I was going to mention that I have several beacons:

the there must be something wrong, because I can’t dispense it beacon – which incidentally came into action for the patient just mentioned – nobody takes 20 pills a day without me checking.

The this is a tricky drug beacon – you know warfarin, methotrexate and the like.

the hey I’ve never seen it before beacon – better have a quick look.

and the something has flashed up on the computer beacon – which I immediately think about my answer in court – so you bypassed the warning without at least a simple check?

But my other beacons are very weak. The – this probably isn’t a good idea in this patient – the renal function or hepatic function means a dose reduction and a whole host of others that require a level of insight currently beyond the boundaries of community pharmacy.

The reliance on community pharmacy as a ‘backstop’ to prescribing errors is a problem. There are actually a limited number of errors that you can reasonably expect a community pharmacist to spot. And this reliance might actually be a barrier to improvement. Why worry the community pharmacist will spot it syndrome. I have heard a doctor say with confidence – I didn’t think the dose was right, but I knew the pharmacy would sort it out!

i also worry about the system that is in place to link up safety so that errors can feed through into system improvement and education to actually prevent errors or simple poor prescribing getting through. Where is the primary care equivalent of a hospital system? Where is the NPSA?

So who is responsible?

This responsibility must fall to NHS England. By definition they hold the contracts with both general practice and community pharmacy. Surely this then falls under Domain 5 as it is all about patient safety amongst a group of contractors that the NHS England commission.

So perhaps it is not everyone’s responsibility – the responsibility falls to Jane Cummings or perhaps Dr Mike Durkin? Well someone there in the NHS England domain 5 group.

On reflection, perhaps it is a good job that they have David Cousens in their midst, but the job is to joining medical education, to prescribing, to dispensing, to feedback and back into safer systems and better education at both a local and national level.

Where should they start and whose help should they employ? Well the answer is not community pharmacy! The CQC have already commented on the lack of medicines reconciliation in general practice, the low level of face to face medication review and the poor systems and completion of critical incident analysis in general practice. I might also add questionable levels of educational support, local prescribing audit capability and general feedback mechanisms.

I assume that the CQC will pay particular attention to outcome 9, Management of Medicines within their provider compliance assessment visits and supportive CCGs will take a positive interest.

It is such a pity that practice pharmacists, employed by the old PCTs have not been employed by practices wishing to get ahead of the game with regard to fulfilling their registration requirements, nor been supported in that function by CCGs. Their real ability to create an improved link between general practice and community pharmacy will become very important.

So lets stop pretending that the system is safe – it is really not – and let’s see the Domain 5 team at NHS England come out and sort it with the support of the CQC and the CCGs.



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