Medication Without Harm, the World Health Organization’s third global safety challenge, was launched last year. At CPPE, we encourage you to take an active role in this WHO initiative by completing this CPPE learning campaign.
Patient safety is integral to what pharmacy professionals do, but due to the nature of your work, within your practice there will be inherent risks. We aim to help you consider what these risks are and how to minimise them. We also intend to support you to manage incidents when they do occur.
You will have received a hard copy of our Risk management guide. You will need this to complete the third challenge of the CPPE campaign but we recommend that you start working your way through the guide as soon as possible to give you a background to the concepts that we will be exploring.
This campaign will follow a patient through a real life scenario. Each challenge aims to help you reflect on your own practice and how to minimise risk.
When you complete all six challenges not only will you receive a virtual badge to add to your collection on your CPPE learning record but you will receive a downloadable poster to display which shows your commitment to patient safety. This poster is endorsed by the National Institute of Health Research (NIHR) Greater Manchester Patient Safety Translational Research Centre.
Use the arrows to scroll between the weekly challenges.
There are six weekly challenges to get your teeth into. If you complete all six challenges you will receive the Patient safety learning campaign badge in your Badge collection in My CPPE.
Don't forget to sign up using the button below and encourage your colleagues and friends to take part too.
Welcome to this first challenge. Those working in healthcare often find themselves in a position where they have a heavy workload and some may find it difficult to speak up about this, which can create a feeling of isolation.
Erica works at a general practice surgery. She’s relatively new and is finding it hard to stay on top of her workload. One of her jobs is to issue prescriptions. Late on a Friday afternoon she was handed a message to say that Bhavisha Patel had lost her lamotrigine and needed a new prescription.
Erica issued a script for two weeks to last until her next repeat prescriptions were due. She selected the wrong patient with the same name as there were two Bhavisha Patels at the practice. The prescription was never collected but the wrong Bhavisha’s Summary Care Record (SCR) was updated as a result of the prescription being generated.
There are several factors that may have contributed to this, reflect on what you think these are.
You can then explore some of these factors in more detail with our e-challenge.
You can face many barriers in your practice. These may include time constraints, lack of communication from other healthcare providers and factors which prevent effective communication with patients.
Bhavisha Patel is 74 years old. She suffers from heart failure and was admitted to hospital yesterday. The ward-based pharmacy technician, Ronda, came to ask for Bhavisha’s permission to access her Summary Care Record (SCR), which she granted. Bhavisha then went outside for a cigarette. Ronda wrote up the drug history and indicated that she had only used one source and that it needed to be followed up; she then left the drug history on the pile of histories for the pharmacist.
The pharmacist, Leon, went to speak to Bhavisha but the curtain was pulled around her bed. He decided that the SCR was probably the most accurate source anyway. As none of the medicines on the SCR were prescribed he asked for them all to be written up, including a recent lamotrigine prescription.
There are often things that get in the way of us completing tasks. One of those can be a reluctance to approach patients and this can be for a multitude of reasons. Speak to your colleagues and discuss what these barriers can be.
Record what you have learned from your discussions here:
Effective communication is vital for safe practice, but in reality there may be things that prevent this, for example a lack of time and resource or problems with the systems we are part of and the processes we undertake.
The next day Bhavisha was discharged home with a seven day supply of all of her medicines and a discharge letter which stated that lamotrigine was one of her regular prescriptions. Some of the heart failure medicines had been altered and there were instructions to review the doses of these medicines in two weeks’ time. There was no mention of the lamotrigine or the newly started morphine that she had been prescribed in the summary section of the discharge letter but they were on the medicines section.
Lilly, a GP working at Bhavisha’s surgery, reviewed the discharge letter a couple of days later. Due to a lack of time Lilly updated the medicines record and asked the receptionist to book an appointment with Bhavisha for two weeks’ time. She then asked Holly, the practice pharmacist, to reconcile the repeat medicines. Holly didn’t notice the lamotrigine in the acute section of Bhavisha’s record but did notice that there was no mention of starting the lamotrigine in the discharge letter, but in her experience this quite often happens. She put a note on the system to ask that this was discussed with Bhavisha at her next appointment. Holly then issued a repeat prescription for all of her regular medicines as she noted that Bhavisha would soon run out. This was automatically sent to Bhavisha’s community pharmacy, who hadn’t seen a copy of the letter. When the GP receptionist contacted Bhavisha to book an appointment, the next day that she was available was in a month’s time.
At this point in the scenario many systems and processes have impacted on Bhavisha. There have also been many factors affecting her care and the healthcare professionals who have been looking after her. This is the same in any area of practice.
You will have received a Risk management guide. Challenge 3 is to work with colleagues and use sections 3 and 4 of this guide to perform a risk assessment for one of the processes that occurs within your practice and to outline a strategy to manage any risks associated with this.
Select the date when you completed this challenge:
Working with patients to enable them to stay in control of their medicines, wherever possible, can help reduce risk. In our scenario Bhavisha was not informed about why lamotrigine was prescribed and she wasn’t given the opportunity to query the details of the prescription. In this next step of her story she could again have helped to resolve the issue.
In this challenge you learn what has happened to Bhavisha and you find yourself in a position where you realise that there has been an error and you need to report it.
The final challenge for this campaign is to reflect on this scenario and identify any points where you could have prevented the incident from happening or progressing. This will help you to identify how you can improve the quality of the services that you and your team offer.
"Patient safety is everyone’s priority. Nobody believes healthcare professions set out to harm patients; however, there are circumstances that combine to make it easier for mistakes to happen. This CPPE learning campaign is about understanding these circumstances and the processes inherent in making a safer system. Its purpose is to make you think about the potential for error and increase your awareness and ability to detect and mitigate error-prone situations. It is very easy to support such a campaign."Dr David Gerrett, Senior Pharmacist Patient Safety, NHS Improvement
The National Pharmacy Association (NPA)
"The National Pharmacy Association is dedicated to improving patient safety in community pharmacy, as well as promoting reporting of dispensing incidents in an open and honest manner. Patient safety is at the core of the NPA, as shown by the short listing of the association for the “Best Patient Safety Improvement Team” at the Patient Safety Congress in 2017. As well as ongoing concerns such as look alike, sound alike errors, it is vital that community pharmacy teams are aware of patient safety issues.”Leyla Hannbeck Chief Pharmacist and Director of Pharmacy, National Pharmacy Association
Royal Pharmaceutical Society
"Improving patient safety is a key priority for all pharmacists and we welcome this new campaign from CPPE. Training and supporting pharmacists to use quality improvement tools to develop the safety of the services they offer patients is essential for delivering a high quality and safe experience for patients."Robbie Turner, RPS director for England
Pharmacist Support – the profession’s independent charity – we are committed to supporting pharmacists and their families, former pharmacists, trainees and MPharm students through any difficult situations they may face, professionally or personally. Our free and confidential services are designed to support pharmacists in carrying out their essential role in maintaining the health and safety of the public and to equip them with tools and techniques to help them deal with any pressures they may face. Support includes a wellbeing service (covering stress and resilience, assertiveness and time management), an information and enquiry service, a stress helpline, debt, benefits and employment advice, financial assistance, careers coaching and addiction support.
The General Pharmaceutical Council
The General Pharmaceutical Council’s key aim is to protect, promote and maintain the health, safety and wellbeing of members of the public by upholding standards and public trust in pharmacy. We produce standards, guidance and a range of resources to support pharmacy professionals and registered pharmacies to provide safe and effective care.
Specialist Pharmacy Service
"I’m right behind the CPPE patient safety campaign as an introduction to improving awareness of medication safety and I feel it is quite timely as I’m expecting the official launch of NHS’s response to the WHO Medication Without Harm Patient Safety Challenge in the spring. The Specialist Pharmacy Service website will be hosting a repository of good practice examples for the WHO challenge so do continue to check the SPS site for information.”Jane Hough, associate director of medicines use and safety for Specialist Pharmacy Service
Medication Safety – Steve Williams
We hear from Steve Williams, senior clinical pharmacist in general practice, in challenge 5.
To learn more about one of the projects which Steve has been involved with watch this video about the medication safety thermometer.
Stay Well Pharmacy campaign
"The need for continuing professional development reflects the growing requirement from the public for clinical advice from community pharmacy for minor health concerns, which is why this year's CPPE campaign fits very well with NHS England's first ever, public-facing 'Stay Well Pharmacy' campaign which runs to March 2018."Dr Bruce Warner, deputy chief pharmaceutical officer
Pharmaceutical Services Negotiating Committee (PSNC)
"Improving patient safety is at the heart of all that community pharmacy teams do, and at PSNC we are committed to doing all that we can to support them in that endeavour. The community pharmacy patient safety group has been making great strides in this area, helping the sector to find ever more ways to learn from experience and find ways to collectively improve patient safety. This latest CPPE campaign will only help those efforts, and we look forward to seeing how community pharmacy teams take part and share their experiences over the next six weeks."Alastair Buxton, director of NHS services at PSNC
Care Quality Commission (CQC)
The CQC publishes a range of resources for providers such as the Adult social care medicines FAQs which can be found in the ‘see also’ section of the Adult social care: information for providers page of the CQC’s website.
Association of Pharmacy Technicians UK
Patient safety is paramount and is at the heart of Association of Pharmacy Technicians UK (APTUK), the professional leadership body for pharmacy technicians. APTUK actively promotes the reporting of errors and subsequent learning activities to its members and the wider pharmacy technician profession. In support of the CPPE Patient safety spring campaign we are delighted to signpost the following information:
Primary Care Pharmacy Association
"The Primary Care Pharmacy Association (PCPA) is totally supportive of the key role that pharmacy professionals have to play in improving patient safety, ensuring systems and medication use are as risk free as possible and encouraging sharing of best practice and safer prescribing. PCPA also promotes and enhances the important role of pharmacists and pharmacy technicians in reducing errors in care homes. Patient safety is the theme for our annual member conferences in summer 2018 and we encourage all pharmacy professionals working in primary care to participate."Liz Butterfield, President, Primary Care Pharmacy Association
The Patients Association
"Patients deserve high quality and safe care which meets their needs. At the Patients Association we firmly believe that patients, their family and carers should be represented and heard at all stages of service development. From gathering patient feedback, to developing patient involvement, it’s vital that pharmacy professionals engage with campaigns like this one, in order to challenge and improve best practice and keep patients at the heart of all their work."The Patients Association
Community Pharmacy Patient Safety Group (CPPSG)
We hear about the work of the CPPSG from group member José Moss as part of challenge 5.
The CPPSG’s priorities for 2018 are now available.
For further resources visit the CPPSG’s resource hub, or click on the principles wheel to learn more about the CPPSG.
Challenge is to make a pledge on how you can make a change. Here we will show your pledges (latest 100 shown):