Pharmacy Quality Scheme – Patient safety report
Pharmacy Quality Scheme – Patient safety report
Community pharmacy contractors passing the gateway criteria will receive a payment for the Pharmacy Quality Scheme if they meet one or more of the domains. The risk management and safety domain consists of five quality criteria, one of which is that on the day of their declaration (which must be done between 3rd February 2020 and 28th February 2020):
‘pharmacies must have a new written safety report (i.e. new since 15 February 2019 (the last review date) or covering the last year if not previously claimed) at premises level available for inspection from the day of the declaration covering analysis of incidents and incident patterns (taken from an ongoing log), evidence of sharing learning locally and nationally, and actions taken in response to national patient safety alerts.
Demonstrable learnings from the CPPE LASA e-learning should also be incorporated into the safety report. This should include a review of, and subsequent actions, where mitigation taken has failed to prevent a LASA incident or LASA near miss from occurring. Demonstrably, the pharmacy contractor actively identifies and manages the risks at premises level associated with the specified LASA medicines identified from the National Reporting and Learning System (NRLS)*.
Demonstrably, the pharmacy contractor has put in place actions to prevent these risks, for example physical separation, staff awareness raising, visual warnings, tags or labels on shelving, fatigue reduction strategies or enhanced checking procedures for these medicines.
There must be demonstrable evidence of all actions identified in the patient safety report having been implemented.
Demonstrably, the pharmacy contractor uploads any LASA incident reports to the NRLS and keeps a record for confirmation of this activity at the pharmacy premises or within any electronic reporting system used by the contractor. In the description of what happened in the NRLS report, the contractor must include the text ‘LASA’ as a unique identifier to facilitate future national learning.
*NHS Improvement top combinations by likelihood and harm caused – propranolol and prednisolone, amlodipine and amitriptyline, carbamazepine and carbimazole, rivaroxaban and rosuvastatin, atenolol and allopurinol’.
Click on a heading below for more information.
NHS England and NHS Improvement guidance
How to achieve this quality criterion (includes guidance and template reports)
Contractors who claimed for this criterion in the previous declarations will not be able to use the same patient safety report to make a claim in February 2020. For the February 2020 declaration they will need to produce a new report to show how the following details have been updated and refreshed since their previous patient safety report was completed:
- collated incidents and near misses from an ongoing log;
- analysis of the incidents and near misses and have looked for patterns;
- reflected on learning from these incidents and near misses;
- recorded action taken to minimise future risk from repeated errors;
- shared learning (both nationally and locally); and
- evidenced specific actions taken by the pharmacy in response to local errors and national patient safety alerts issued by the Central Alerting System.
Demonstrable learnings from the CPPE LASA e-learning should also be incorporated into the safety report. This should include a review of, and subsequent actions, where mitigation taken has failed to prevent a LASA incident or a LASA near miss from occurring. The contractor must be able to demonstrate having actively identified and managed the risks at premises level associated with the specified LASA medicines identified from the National Reporting and Learning System (NRLS) as shown below:
- Propranolol and prednisolone;
- Amlodipine and amitriptyline;
- Carbamazepine and carbimazole;
- Rivaroxaban and rosuvastatin; and
- Atenolol and allopurinol.
These pairs have been identified from Coroners’ reports and/or the NRLS. Incidents involving these pairings are reported with considerable frequency, have been associated with serious harm and the medicines are pharmacologically disparate.
The contractor must be able to demonstrate that actions have been put in place to prevent these risks, for example, physical separation, staff awareness raising, visual warnings, tags or labels on shelving, fatigue reduction strategies or enhanced checking procedures for these medicines.
There must also be demonstrable evidence of all actions identified in the patient safety report having been implemented.
The contractor should upload any LASA incident reports to the NRLS and keep a record for confirmation of this activity at the pharmacy premises or within any electronic reporting system used by the contractor. In the description of what happened in the NRLS report, the contractor must include the text ‘LASA’ as a unique identifier to facilitate future national learning. Including in the incident description details of the actions that had been in place in the pharmacy to prevent LASA errors from occurring will help inform learning about the mitigation used in community pharmacy to prevent these errors.
Reporting errors to the NRLS
Contractors already have a contractual requirement to report patient safety incidents to the National Reporting and Learning System. This can be done via the e-form following guidance on the PSNC website, and some contractors collate reports via corporate systems, which then report centrally to NRLS. When LASA incidents are reported to NRLS directly or via other systems, in the description of what happened in the incident, ‘LASA’ should be included. This will enable NHS Improvement to search for LASA-related reports and information and learning from such incidents can be maximised.
Copies of patient safety incident reports made by a pharmacy to NRLS or to corporate or other incident reporting systems should be retained by the contractor.
Guidance and resources
PSNC has worked with the Community Pharmacy Patient Safety Group to produce Pharmacy Quality Scheme (PQS) – Completing the Patient Safety Report which provides contractors with information on what they need to do to meet the quality criterion, as well as worked examples of the monthly and annual patient safety report templates
PSNC, the Community Pharmacy Patient Safety Group and NHS Improvement have created the below templates (these have been updated for the 2019/20 PQS), which contractors may choose to use to create their report; these templates are also included in Annex 4 and 5 of the NHS England and NHS Improvement PQS 2019/20 guidance.
A template to collate and review patient safety incidents each month:
A template to complete the annual written patient safety report:
The annual patient safety report does not need to be submitted to NHS England and NHS Improvement routinely but contractors should ensure that a copy of the report is kept in the pharmacy.
Pharmacy professionals are advised, if not already done so, to complete the Centre for Pharmacy Postgraduate Education (CPPE) Reducing look-alike, sound-alike (LASA) errors e-learning and assessment before completing the patient safety report (this is a separate quality criterion of the PQS) as demonstrable learnings from the CPPE LASA e-learning should also be incorporated into the safety report.
There are several different ways that contractors can share learning locally. This might take the form of a meeting with local general practices to share learning from incidents or near misses, sharing learning with other local pharmacies, a Local Pharmaceutical Committee (LPC), Local Professional Network (LPN) or Local Practice Forum (LPF) event, or sharing via a newsletter.
- PSNC has developed a Patient safety information page that contains a quick reference guide to patient safety alerts, recalls, advice and guidance relating to patient safety which have previously been highlighted as news stories on the PSNC website and a link to the Medicines and Healthcare products Regulatory Agency (MHRA) monthly drug safety updates.
- The Community Pharmacy Patient Safety Group has published resources to help pharmacy teams with discussions around LASA errors. Community pharmacy teams may find these useful when working towards achieving the patient safety report quality criterion of the PQS.The resources, which were developed, inspired and informed by the Boots UK ‘Drug of the Month’ posters, include a series of one-pager resources – contains informative LASA medicine dispensing and checking tips; and a poster – contains useful background information on LASA errors and summarises some of the Group’s LASA work.
FAQs on the Pharmacy Quality Scheme can be found on the Pharmacy Quality Scheme – FAQs page.