Sharing best practice
Lead by example. Here are some of your case studies and examples of meeting the standards, good practice and lessons learned.
The General Pharmaceutical Council (GPhC) notable practice for inspection examples:
See GPhC knowledge hub website for further examples.
Controlled drugs diversion on ward – Shalini Gujral, Chief Pharmacist Private Sector
While undertaking the weekly pharmacy top up on the ward, the pharmacy assistant noticed an empty box of dihydrocodeine 30mg tablets and an empty box of diazepam 2mg tablets in the medicine stock cabinet. Both boxes were pristine with no evidence that they had been dispensed from. The drugs could not be located in the medicines cabinet or clinical room. She notified the ward pharmacist who confirmed no patients had been on these drugs for the last month. The Chief Pharmacist and Hospital Director (who is also the CDAO) were notified immediately. The clinical notes of patients attending in the last two weeks were checked, and no diazepam or dihydrocodeine had been prescribed. The incident was recorded on Datix and treated as a diversion. The following external bodies were notified about the diversion: the CD LIN, the CDLO and the Home Office. As part of the investigation, staff with access to the clinical room and drug cupboards were interviewed. These interviews highlighted that drug security in the clinical room on the ward could not be assured at all times, as the drug cabinets were sometimes unlocked. The missing drugs could not be accounted for, but changes were made following this incident, including medicines management and security training for staff and increased security measures of schedule 4 and 5 CDs. Policies were updated and disseminated after this change, so all staff were aware of the new CD requirements. This incident highlighted the importance of reviewing processes following an incident and acting accordingly. A copy of the investigation was provided to the external bodies notified about the incident.
Prescribing methotrexate 10mg tablets incident – GP practice
Methotrexate (MTX) was prescribed as 10mg tablets, take two tablets 2 weekly (supply of eight tablets). The patient took all eight tablets (80mg) as one dose as they thought they were 2.5mg tablets (what is usually prescribed) despite apparently two pharmacies informing him of the different strength and the pharmacy dispensing the prescriptions reiterating this and informing of the dose change, i.e., two tablets a week. 10mg tablets should not have been prescribed, but the prescription was for the correct dose and direction was issued.
On realising the problem, the pharmacy was informed. The pharmacy contacted the patient and confirmed they had taken the above dose, and they advised the person to go straight to hospital. The bloods taken in hospital were monitored by the surgery. The patient was contacted to arrange for repeat bloods. The surgery informed the patient’s consultant of the events, who confirmed to withhold MTX for two weeks (the patient was going on holiday so the consultant advised the medication be withheld until their return, as they were going to a sunny location (risk of photosensitivity)).
What could have been done better?
- Staff involved in the process to take more diligence and check before overriding computer system warnings and questioning if messages don’t appear correct
- The GP could have noticed before signing script
- Pharmacy A could have returned or highlighted that 10mg were prescribed and queried this to the practice and not given the script to the patient to take to another pharmacy
- Pharmacy B could have returned or highlighted that 10mg were prescribed and queried this to the practice and not dispensed the prescription.
Reflections on the event
The person who amended the strength from 2.5mg to 10mg after receiving hospital letter to increase the dose was an administrative member of staff. They had undertaken some external learning on DMARD drugs and at no point in the training resource was any issue of prescribing 10mg tablets raised. Review of resources highlighted original National Patient Safety Agency (NPSA) documents on this now on archived gov.org website. BNF states “do not prescribe 10mg tablets” but underneath it, reflects the wording of a current NPSA alert where prescribers are advised “consider the patient's overall polypharmacy burden when deciding which formulation to prescribe, especially in those with a high pill burden”. On discussing with the person that altered the repeat, they stated that they were thinking to reduce the number of tablets but were not aware of the BNF guidance.
Changes made
The person involved undertook additional training and has themselves done a personal reflective account on this. If printing prescriptions for MTX or any DMARDS, recent blood test results must be printed and attached to the prescription to give the prescriber for added awareness of a high-risk drug and to check thoroughly before signing.
Pauline Lockey Patient Safety Clinical Lead (Medication Safety) NHS England
As a patient safety clinical lead in NHS England’s National Patient Safety Team, a core part of my work is to identify patient safety risks that occur in the delivery of healthcare. Where a risk has been identified, I work with colleagues to develop advice and guidance to support the NHS to take action to address those risks and keep patients safe. I’m part of a wider team that reviews patient safety events recorded by staff and patients on our national systems to identify new or under-recognised patient safety issues. In some cases, an identified new or under-recognised risk will meet the criteria for a National Patient Safety Alert, but where this doesn’t happen, we look to work with partner organisations which may be better placed to take action to address the issue.
As an example, we identified a report that outlined that a baby required hospital treatment for seizures, following administration of doses of phosphate that were 16 times higher than intended; effervescent phosphate tablets were used to administer the doses of phosphate. Our analysis of reported patient safety events data, identified a number of concerns relating to the use of portions of phosphate or calcium effervescent tablets in children. There were indications that errors occurred at each stage of the medicine journey – prescribing, dispensing, preparation and administration.
There are no licensed oral liquid calcium or phosphate products available in the UK. Administration of a portion of a licensed effervescent calcium or phosphate tablet is common, and such off-label practice is challenging and prone to error. Collaborative working with several partner organisations led to publication of the following resources and delivery of a webinar to the national medication safety officer network:
Further case studies can be found on the NHS England Patient safety review and response case studies by clinical specialty. These highlight the importance of recording patient safety events and the direct action the National Patient Safety Team takes in response to patient safety events recorded by organisations, staff and the public, and how their actions support the NHS to protect patients from harm.
Leanne Gurney, Medicines Safety Pharmacy Technician in England
As a Medicines Safety Pharmacy Technician working in an Acute Hospital Trust, I work alongside the MSO. Together, we promote the safer use of medicines, managing medication incidents in the organisation, and improving the reporting and learning from these. We do this by working with multi-disciplinary teams and healthcare professionals. Shared learning across our Trust is promoted in a variety of ways, such as our Medicines Event Review Group, Learning from Events Forum and during quality reviews.
When reviewing our pharmacy incidents, we ensure we take a just culture approach and look at the incident both in detail and systemically. It’s important to understand the psychological impact an error can have on an individual and how it can lower confidence in practice, while valuing professional accountability. We have reflective conversations with our colleagues, ensuring that we handle the conversation constructively and give the individual an opportunity to be open and honest in a safe space, while we in the medicine’s safety team remain professional and empathetic towards them. There are a multitude of factors that contribute towards errors and those that are highlighted, tend to funnel into the environmental factors, such as physical or external influences like tiredness or distractions. We also have our colleagues involved in errors fill out reflective accounts in their own time, sometimes individuals prefer doing this as it gives them more time to think about the situation and any personal circumstance that contributed towards the error that they may not want to divulge during the conversation.
As pharmacy technicians within the pharmacy team, we can really make an impact to our patient care by being open and honest when errors have occurred. And understanding, through the investigation, the reasons why they happened gives us the opportunity to make our Trust a safer place to work.
A medicines safety alert was issued regarding potassium permanganate soak tablets, which are used to treat skin conditions that blister or weep. They are to be diluted in water and the affected area of skin, soaked in the solution. However, when patients have ingested it orally it has caused death or severe harm even in a hospital setting. The medication safety team liaised with stakeholders for a multidisciplinary approach to review the entire treatment pathway with necessary risk assessments in place. When reviewing systems and processes for safety, it is important to consider removing barriers as well as adding additional steps – a complex process has potential for mistakes or non-adherence.