Written patient safety report

NHS England has now published its full guidance for the Quality Payments review date of Friday 15th February 2019. This section of the website is currently being updated to reflect the new guidance. The information below relates to June 2018’s Quality Payments.

Note: The information on this page is a summary of the requirements for June 2018’s Quality Payments. We strongly advise pharmacies to read the full NHS England guidance as well – there are links at the end of this page. Download this page as a PDF.

Written patient safety report (June 2018)

Points available: 20 points (£640-£1,280) available.

What’s involved:

On 29th June 2018, you must have a written patient safety report available for inspection at your pharmacy. The report needs to include analysis of incidents and any incident patterns in your pharmacy (based on your ongoing incident log), evidence of sharing learning locally and nationally, and the action you’ve taken in response to national Central Alerting System (CAS) patient safety alerts.

Your report must have been updated or published since 24th November 2017. You can’t use the same report as last year, but you can use an updated version including new learning, sharing, actions etc.

Evidence required

  • You need to have a written copy of the report on your premises.
  • Make sure all staff are familiar with the report’s contents and know where the printed copy is located so they can locate it easily if asked (e.g. during an inspection/validation visit).

 Key requirements

  • You need to have been recording incidents and near misses in an ongoing log, and reporting them to the National Reporting and Learning Service (NRLS). Pharmacies were already expected to do this before Quality Payments (see the NHS England guidance and RPharmS standards – links at end).
  • The report needs to be specific to your individual pharmacy, i.e. not a general one covering different branches or the sector as a whole.
  • You need to show you have collated incidents and near misses from your log, analysed them and looked for patterns.
  • You also need to show you have reflected on any learning from incidents/near misses and any patterns.
  • The report should explain what action you have taken to minimise the risk of incidents/near misses reoccurring.
  • Demonstrate how you have shared your learning locally and nationally (e.g. by reporting incidents). Local sharing could include meeting GP practices to talk about incidents/near misses, sharing information with other local pharmacies, or via Greater Manchester LPC. We are happy to do this via our newsletter and website.
  • The report also needs to say what action you have taken in response to CAS safety alerts (Central Alerting System) as well as local errors and any other incidents/risks you’ve been made aware of. Action should be appropriate to the level of risk.

 What kinds of incidents/near misses should be included?

  • Include errors and near misses involving medication that have caused the patient harm or had the potential to do so. NHS England says documentation errors and errors picked up early in the dispensing process don’t need to be included.
  • Examples include adverse reactions, delivery incidents, miscommunication between prescribers/dispensers, controlled drug errors/discrepancies, errors handing out medicines, drug interactions and prescribing errors – i.e. not just dispensing errors.

Useful templates

The PSNC website has fantastic templates to help you record incidents each month, and to produce your written patient safety report. It also includes examples of monthly and annual reports. Access them here in the ‘How to achieve this quality criterion’ section.

Top tips when writing your report & general patient safety

  • Demonstrate you have a patient safety culture in your pharmacy: Report, Learn, Study, Act.
  • Make sure the report covers the last 12 months if possible, it is written and owned by the whole team, and that everyone understands the learning and actions.
  • Cover the last 12 months if possible.
  • Show continuous improvement by reflecting and learning from incidents.
  • Respond in a proportionate way (i.e. appropriate to the scale of the risk). Don’t focus so much on one thing that you ignore or overlook others.
  • Have user-friendly pharmacy processes that are easy for staff to follow.
  • We would recommend signing up for safety alerts from CAS, NHS Improvement, etc if you haven’t already done so. There are links at the bottom of this page.

Full guidance from NHS England

This tip-sheet is just a summary. You must also read the full NHS England guidance to make sure you meet the Quality Payments criteria. There are 3 key documents:

  • Updated guidance for June 2018
  • Gateway Criteria Guidance
  • Quality Criteria Guidance

Further guidance and useful links