Specific section changes
|
Title (new)
|
Feedback from the consultation and steering group included providing clarity on what these standards are for and what incidents it relates to. They should be patient safety standards. In response we updated the following:
|
Introduction (new)
|
-
Covered the background of the standards, what these standards are for, how they fit with other legislation, regulatory standards, other standards, policies and procedures, and what patient safety incidents they cover
-
Described the relationship between a GPhC regulatory standard and an RPS professional standard.
-
New figure 1 – illustrates where RPS professional standards fit in relation to legislation, regulatory standards, other standards, policies and procedures.
|
Purpose (new)
|
Feedback from the consultation and steering group included providing information on why we need the standards, why it’s important to follow them and how they can support you to protect people who use pharmacy services. In response we updated the purpose section with the following:
-
Provided clarity on why we need the standards, the importance of implementing them, patient expectations, how they can be used to protect people who use pharmacy services and how everyone is equally responsible in supporting patient safety
-
Updated and integrated section 3: ‘how patients who use pharmacy services are protected’ into the purpose
-
Updated and integrated section 4: ‘how reporting, learning, sharing, taking action and review are fundamental to patient safety’ into the purpose
-
Key themes include person-centred care, health equality and equity, patient safety culture, empowerment, service design, professionalism, leadership, skill mix, capacity, capability.
|
Scope
|
Feedback from the consultation and steering group included explaining what to record and how to use the standards. The audience needs to be defined clearly as well as roles and responsibilities of all individuals in the team. The scope needs expanding to include changing workforce models as its currently very community focussed. In response we updated the scope section with the following:
-
Updated and expanded scope for clarity
-
Expanded audience – who they apply to and who else they may be of interest to and how, focus on pharmacy as these are pharmacy standards
-
Expanded setting and sector – include all pharmacy services, not just community pharmacy. Applies to anyone delivering pharmacy services, pharmacy professionals working in other healthcare settings and anyone working within the pharmacy, regardless of professional background or setting
-
Expanded geographics – now focuses on all pharmacy sectors and settings across UK and Northern Ireland, not just community pharmacy
-
Added general scope of standards – they are generic standards that need to be contextualised
-
Added how to use the standards.
|
The standards
|
-
There are now seven standards (previously six) setting the outcome and expectation for clarity and consistency of terminology
-
New – ‘reflect’ and ‘evaluate’
-
Updated – ‘be open and honest’ and ‘record and report’
-
Merged – ‘share’ and ‘learn’.
-
Seven new and updated descriptor outcomes – to provide more details and support attainment of the standard by describing what should be actively and routinely demonstrated and why
-
37 new supporting statements – explaining how a standard and descriptor could be demonstrated
-
These have been added in response to feedback from the consultation and steering group to provide clarity
-
33 new further information sections - information and examples that provide clarity and meaning to the supporting statements and to keep the supporting statements unique and in scope
-
New figure 2 – structure of the standards and an explanation on how to use them
-
New figure 3 diagram of Professional standards for responding to patient safety incidents (adapted from Community Pharmacy Patient Safety Group). We created a new diagram to incorporate the needs mentioned in the consultation.
|
Glossary (new)
|
Added new terms: ‘patient safety incident’ and ‘harm’.
|
References
|
|
Website
|
|
Further details of changes to the standards
|
Reflect (new)
|
Feedback from the consultation and steering group included reflection as an important activity to include. In response, we updated the section with the following to provide clarity:
Added:
-
New standard
-
New descriptor outcome
-
New supporting statements and further information for: 1.1, 1.2, 1.3, 1.4, 1.5 and 1.6.
New key themes:
Being proactive, regular reflection, safety culture, systems, existing practice, identify gaps and learning needs, improving the delivery of safe and effective person-centred care, understanding your own and others’ roles and responsibilities, continuous professional development, work-system based factors, socio-technical systems, system-based approaches, addressing issues and concerns, developing processes and policies collaboratively, causes of errors, barriers to reporting, using existing national, local and regulatory guidelines, training, access to IT tools and systems and having resources in place, e.g., staff and time, SEIPS, risk tolerance, risk management and thematic review.
|
Be open and honest
|
Feedback from the consultation and steering group included making the outcome clearer by providing more detail, e.g., rationale, importance, what actions demonstrate that you have been open and honest, when to be honest, who needs to be honest, who you need to be honest with or how you can be honest. In response, we updated the section with the following to provide clarity:
Added:
-
Updated to include ‘open and honest’
-
New descriptor outcome – what should be actively and routinely demonstrated and why
-
New supporting statements and further information for: 2.1, 2.2, 2.3, 2.4, 2.5 and 2.6 – to explain how the standard and descriptor could be demonstrated and examples.
New key themes:
Be responsive, accountability, just culture, psychological safety, promoting psychological safety, duty of candour, transparency, whistleblowing, empowerment, accountability, challenging poor practice without fear, who to be open with and who to keep informed and involved, wellbeing, safety, communication needs, involving affected individuals, actively listening, providing information and support and MHRA Yellow Card self-reporting.
|
Review
|
Feedback from the consultation and steering group included making the outcome clearer by providing more detail, e.g., rationale, importance, frequency of review, reviewing impact of changes to practice/actions, review effectiveness, how to measure and monitor changes to practice, monitoring and measuring impact, analysing data, timeframes, review of procedure and service evaluation, what to review (intervention, IT systems, risk management procedures), use of tools, safety I and safety II thinking, reviewing what’s going well. In response, investigation elements were moved here and we updated the section with the following to provide clarity:
Added:
-
New descriptor outcome
-
New supporting statements and further information for: 3.1, 3.2, 3.3, 3.4, 3.5, 3.6 and 3.7.
New key themes:
Investigate in a timely manner, contributing factors, determine an appropriate response or action, gather and analyse data, systems-based, investigate, thematic reviews, system-based interventions, risks, themes, trends, patterns, behaviours, frequency, documentation, enquires, corrective or preventative measures, recommendations, audits, complaints, compliments, peer discussions, near miss logs, environment, technology, people, work systems, socio-technical systems, human factors, complex factors, incident analysis, risk identification, identify root cause, support safety interventions and learning, incident investigation tools, improvement methodologies and mechanisms, SEIPS, systems-based learning, involve others and safety I and II approach.
|
Report and record (new)
|
Feedback from the consultation and steering group included making the outcome clearer by providing more detail, e.g., rationale, importance, what what to report, when to report, how to deal with errors identified by a different organisation, who to report to, inclusion of SOPs, GDPR, collaboration, what to record. In response, we updated the section with the following to provide clarity:
Added:
-
New standard ‘report and record’ to replace ‘report’ – focuses on recording, reporting and sharing info with the right people/organisations.
-
New descriptor outcome – what should be reported and why
-
New supporting statements and further information for: 4.1, 4.2 and 4.3 – to explain how the standard and descriptor could be demonstrated and examples.
Added:
New key themes:
Timely, internal, local and national reporting mechanisms, escalation, facilitate learning, record, report, information, reporting systems, secure, data protection, discussion, advice, collaboration, learning, what to report and record, good practice, culture, service quality, who you involved, generate new ideas, motivation to report and how to deal with errors identified by a different organisation.
|
Act
|
Feedback from the consultation and steering group included making the outcome clearer by providing more detail, e.g., rationale, importance, who should action, what to action, assessing reactive and proactive response, reviewing systems, strengthening systems, sustainable changes and follow up. In response, we updated the section with the following to provide clarity:
Added:
-
New descriptor outcome – what action to take and why
-
New supporting statements and further information for: 5.1, 5.2, 5.3, 5.4, 5.5, 5.6 and 5.7.
New key themes:
Timely, manage risk, quality of practice, systems of care, e-Systems, sustainability, addressing contributory factors, system weaknesses, latent hazards, systems-based approach, risk-management approach, understand why the incident occurred, develop, reactive, proactive, corrective measures, preventative measures, measure impact, monitor effectiveness, interventions, data collection tools, improvement methodologies, behaviours, implement learning, feedback, acknowledge good practice, support, design, collaborate to identify needs, test, roles and responsibilities, required response, strengthen, improve, system changes, follow up and minimising risk.
|
Share learning (new)
|
Feedback from the consultation and steering group included making the outcome for ‘learn’ and ‘share’ clearer by providing more detail, e.g., rationale, importance, aligning with new patient safety incident response framework recommendations, include what to learn from, who to learn from and why, creating an inclusive learning culture and allocating time for learning. Include how to share, what to share, timeframes of sharing, who to share with and creating a sharing culture and its benefits. Investigate should be a separate and should include involving the patient and what to investigate (e.g. contributory factors/causes, patterns and themes). In response, investigation elements were moved to standard ‘Review’ which focuses on what to investigate and analyse. We updated the section with the following to provide clarity:
Added:
-
New standard ‘Share learning’ to replace ‘share’ and ‘learn’ – merged ‘share’ and ‘learn’ due to overlap
-
New descriptor outcome – what learning should be shared, with who and why
-
New supporting statements and further information for: 6.1, 6.2, 6.3 and 6.4 – to explain how the standard and descriptor could be demonstrated and examples.
New key themes:
Share appropriate learning, who to share with, how to share, why share, learning culture and environment, sharing mechanisms, cascade internally, locally and nationally, benefit and impact of recording, reporting, learning, sharing or acting, learn together, professional, clinical and legal responsibilities, learning from incidents, learning from others, learning to inform improvement, learning from near misses, prevention better, networks, communications, what to share, what went well and what went wrong, inclusive of other professionals and cascade.
|
Evaluate (new)
|
Feedback from the consultation and steering group included separating activities of evaluation and review. In response, we updated the section with the following to provide clarity:
Added:
Added:
New key themes:
Regularly evaluate systems, interventions and changes made, assess outcomes, follow up, appropriate timeframe, appropriate intervals, interpret data, assess impact and effectiveness, risk management approach, have outcomes been met, new interventions identified, assess current systems, IT systems, update, risk management procedures, safety management, what is going well and what could be improved, prescribing and management systems.
|
How patients who use pharmacy services are protected
|
Feedback from the consultation indicated this section was useful and relevant. However, it doesn’t describe an outcome and is not clear how it relates to incidents specifically.
In response to the feedback, this section was removed, updated and included in the ‘introduction and purpose’ section.
|
How reporting, learning, sharing, taking action and review are fundamental to patient safety
|
Feedback from the consultation indicated clarity was needed on the purpose of this section, it was missing elements, e.g., reflection, timeframes, a focus on patient safety, patient-centred care and joint working with the MDT.
In response to the feedback, the section was removed, updated and included in the ‘purpose’ section. The Report, Learn, Share, Act, Review (RLSAR) wheel was removed as it was out of date and mainly community pharmacy focused. We created new standards and a new diagram incorporate the needs mentioned in the consultation.
|
What to report and who to report to
|
Feedback from the consultation suggested moving this level of detail out of the standards and to include addition organisations to report to including Learn from Patient Safety Events, medication safety officer networks, CD local intelligence network, CD accountable officers (via CD Reporting). Inclusion of following employers’/organisations procedures and policies for reporting, sharing errors identified from elsewhere, and where pharmacy teams within general practice/primary care should report.
In response to the feedback, the section was removed, updated and moved to a supporting resource page as it wasn’t within the scope of the standards and more about supporting implementation of the standards.
|
What stops pharmacy teams from reporting, learning, sharing and taking action
|
Feedback from the consultation indicated this section was helpful, useful and important as it clearly explains hesitation to report. There are good examples of issues around non-reporting and excellent descriptions of what needs to be in place to counter these. Improvements included emphasising the benefits of reporting errors and adopting language that is supportive and enabling rather than negative/defensive/blaming.
In response to the feedback, the section was updated and moved to a supporting resource page as it wasn’t within the scope of the standards and more about supporting implementation of the standards. It was retitled ‘Ways to encourage a patient safety culture in the workplace – including a just, open, reporting and learning culture’ to make it more supportive and promote a safety culture.
|