Written patient safety report
Written patient safety report
Points available: 20 points (£640-£1,280) available.
Key changes since last time:
- You now have to show evidence of learning from others on prevention of NHS Improvement’s top 5 ‘look like, sound alike’ (LASA) errors and have put actions in place to prevent them. For example, enhanced checking and/or physical separation of these items.
- You also need to have produced an updated written patient safety report if you claimed this quality payment in June 2018 – you can’t reuse the same report.
- 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).
- You must have a written patient safety report available on your premises for inspection on 15th February 2019.
- The report must have been produced since 29th June 2018. (You can use an updated version of the report you used to claim June’s quality payment but you can’t reuse exactly the same report.)
- The report needs to include:
- Collated incidents/near misses from the pharmacy’s ongoing incident log
- Analysis of these incidents/near misses e.g. any common patterns or trends
- What you have learnt from this
- What action you have taken to minimise future risks
- How you have shared your learning, locally and nationally (e.g. reporting to head office, NRLS or safety forums)
- What action you’ve taken in response to local errors and national CAS alerts
- The report must also include your learning from others on NHS Improvement’s top five ‘look alike, sound alike’ (LASA) errors, and what actions you have taken to prevent them.
NHS Improvement says the top five LASA errors are:
- Propranolol & prednisolone
- Amlodipine & amitriptyline
- Carbamazepine & carbimazole
- Azathioprine & azithromycin
- Atenolol & allopurinol
Action you can take to reduce LASA errors
- Keeping similar looking/sounding items well separated
- Staff training/awareness-raising
- Enhanced checking procedures
- Visual warnings e.g. on your shelves
- Making sure pharmacists/team members don’t get too tired or lose concentration
Reporting LASA errors
Make sure you include the term ‘LASA’ when reporting ‘look alike, sound alike’ errors to head office and/or the National Reporting & Learning System (NRLS).
- Written patient safety report available for inspection on the pharmacy premises.
- Evidence of learning from others on LASA errors, and action taken to prevent them.
Top tips when writing your patient safety report
- Demonstrate you have a patient safety culture in your pharmacy: Report, Learn, Study, Act.
- Include errors or near misses involving medication that have caused, or had the potential to cause, patient harm. (You don’t need to include errors picked up early in the dispensing process or documentation errors.)
- 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.
- 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 MHRA, NHS Improvement, etc if you haven’t already done so. See the links below.
Useful templates & resources:
- Ongoing incident log: You may find this PSNC template helpful for recording incidents/near misses in your pharmacy each month.
- Written patient safety report template: You can use this PSNC template to produce your written patient safety report for Quality Payments. PSNC has produced guidance to help you complete the report, along with examples of completed incident logs and patient safety reports. Click here, then go to ‘How to achieve this quality criterion’, then scroll down to ‘Resources’.
- Reporting incidents to NRLS: All pharmacies are required to record patient safety incidents and report them to NRLS. (If you work in a multiple, the process may be to report incidents to head office who then report them to NRLS.) This PSNC webpage explains more, and includes a link to an e-form for reporting incidents to NRLS – just scroll down to ‘Report an incident’.
- CAS alerts: All pharmacies should automatically receive alerts issued by the NHS’s Central Alerting System (CAS). If you’re not receiving these CAS alerts, email firstname.lastname@example.org to let them know.
- MHRA alerts: You can sign up for drug & device alerts from the MHRA. You can also sign up for their regular Drug Safety Update.
- NHS Improvement: Sign up for patient safety alerts from NHS Improvement.
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 February 2019
- Gateway Criteria Guidance
- Quality Criteria Guidance