reporting of dispensing errors and fear of litigation

[Racer]

Originally Posted by Jeff

Friday I recieved unsigned scripts for 29 items from the addiction unit and four signed scripts for methadone 35ml daily supervised mitte 0 (zero) ml

Do I just get my scripts sorted and call it a day?

I'm logging it as a critical incident.

Jeff

And then you'll take it up with the addiction unit ?

Racer

[Jeff]

And then you'll take it up with the addiction unit ?

Critical incident reporting to the PCT - and I'm visiting the addiction unit Thursday morning.

Jeff

[admin]

Jeff

Critical incident reporting to the PCT - and I'm visiting the addiction unit Thursday morning.

How did your visit go ?

[Jeff]

Got the unsigned scripts sorted - showed them the signed scripts for 0mls of methadone and said I wanted it logged as an "incident" - had a long chat with a drugs worker about what they do.
Further comments I wont post on an open list.

Jeff

[admin]

Jeff

OK fair enough. But don't think those closed forums are that closed!

[Fruitpharm]

It is true that dispensing errors are still classed as an offence, but it will take parliamentary legislation to change that - Fat chance!

In the meantime we are supposed to be working towards a trusting relationship with the PCT so that we can report our offences to them!

As a Clinical Governance facillitator I have one foot in both camps. As a community pharmacist I make mistakes and I also work for the PCT to drive a clinical governance agenda. I know that a PCT will have no option but to be very cautious with a pharmacist that reports errors. This caution is borne out of a fear of litigation should a patient that has suffered harm as a result of an error dispensed by a pharmacy that has previously submitted an error form to that PCT. Having said that, the PCTs are keen to spread any learnings from errors as well as put a process of support and development into the errant pharmacy to reduce any further risks.

On balance I feel we should share, and hence learn from our mistakes.

[admin]

To Fruitpharm

Having said: -

I know that a PCT will have no option but to be very cautious with a pharmacist that reports errors. This caution is borne out of a fear of litigation should a patient that has suffered harm as a result of an error dispensed by a pharmacy that has previously submitted an error form to that PCT.

Do you think that pharmacists should have their name put to errors? And do you think we are right to be worried about using our name? I have (touch wood!) not made an error that has got to the patient for a very long time, but obviously like everyone I have done so in the past. How many errors does it take to get put on the "cautious" list? You used the words "an error" so is it literally just the one?

Thanks for posting and telling us all about your dual role. It's great to have someone with your experience taking the time to post here, and I'm sure it has made a lot of us think quite a bit!

:?

[Anonymous]

Nice to know someone is listening.

The Clinical Governance Managers of the two PCTs I work for are not pharmacists, nor do they have a clear understanding of community pharmacy but through the implementation of the new contract framework they are trying to understand the way we work. I can honestly say there is a real willingness to want to help pharmacists become integrated and benefit from the support the PCT has to offer. (Maybe that's just the PCTs I work for and where you are it is a different picture! )

Basically, if a pharmacy makes a mistake then it may be possible that the PCT can offer some form of help, perhaps support through a process of Root Cause Analysis to identify the factors behind the error. I know that there are many smaller independants, and even some branches of multiples, where there is a need for outide help. My role as CG facillitator allows me to go in and offer that help. This one step along the path to developing a relationship based on trust. How can we develop this relationship if we are to hide behind anonymity?

My PCTs have a process for dealing with poor performance and there is one pharmacy that is going through this process. I can assure you that the pharmacy will be given lots of support and guidance before being referred on, as in this case, to the Society. The PCTs do not want to remove contractors, far from it. They simply want to ensure that the patient gets the quality of service they expect.

Sorry for getting on my soapbox :roll:

[Fruitpharm]

Sorry, I'm new to this "Forum" thing. That last message was mine. It would have helped if I had actually logged in before posting a reply. :?

[Anonymous]

I agree with you completely.
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