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Patient Safety in Community Pharmacy: the importance of teamwork

19 Oct

by Tomasz Niebudek, Pharmacist

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My name is Tomasz Niebudek. I work as a community pharmacist in the Salford area. Last year at the end of May our Superintendent Pharmacist forwarded to me an e-mail asking if anybody would be interested in taking part in a project at The University of Manchester. In a nutshell, the aim of the project was to improve safety in community pharmacy. I expressed my interest in participating, thinking that this would be an interesting challenge, that would allow me to reflect on and improve safety in my pharmacy and across the whole company.

One of the key things that I learnt by joining the collaborative is that we should look, not only at reactive ways of analysing errors, but also use proactive methods  to prevent errors from occurring before they’ve happened. The tool that, in my opinion, had the biggest impact on my practice was PRIMO (Proactive Risk Monitoring for Organisational Learning). This was basically a questionnaire given to all staff members in my team to find out what affects their ability to dispense accurately. This led to many interesting observations and reflections. It was encouraging to see that staff members who are usually quiet during the staff meetings had very strong views on certain matters. Some team members identified a problem and were able to provide a solution to it almost immediately. It was so motivating to see that they care about safety and it was also interesting to discover that my staff members have observed issues that I have never picked up on. I have very carefully analysed all the data from those questionnaires and shared my conclusions with my whole team during a staff meeting. We have straight away implemented changes to our practice. As you all know, change within organisations can be met with resistance by staff. However, the fact that the ideas were generated by the staff themselves made a huge difference (a positive one, of course). Doing that questionnaire made me realise that staff need to be fully onboard when safety is being considered.

I now encourage all staff in my branch to report near misses and dispensing errors, as previously, this was a task only/usually undertaken by myself. We work together to think of ideas to improve practice and safety in the pharmacy. Initially, I was worried that some staff might have the attitude that “this is not my problem”, which is an approach that I think is partially to blame for errors in primary care. However, I’ve learned that if you respect your team for the valuable input they can have in improving practice, and work with them to achieve this aim, it pays back.

Big thanks to The University of Manchester researchers in helping us to look at safety from a different perspective.

The purpose of the Community Pharmacy Patient Safety Collaborative is to work as a group exchanging ideas and sharing experiences. The same approach must be used on an individual pharmacy level- pharmacists can only improve the safety of their patients with his or her team on board.

Community Pharmacy Patient Safety Collaborative: Safety Initiatives

14 Jun

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My name is Chui Cheung, working as a community pharmacist in Wigan, Lancashire.  I joined the NIHR Greater Manchester PSTRC Community Pharmacy Patient Safety Collaborative Study with the University of Manchester in November 2015.  Looking back, it was curiosity that led to my participation and I was worried how I would handle the research projects.  Nevertheless, the title of patient safety attracted me to find out more.

Patient safety is at the centre of our everyday tasks whether we are pharmacists, technicians, dispensers, medicine counter assistants or other members of the team. Whatever we do in the course of our work, we must do it safely.

At the start of the first year project, there were 8 to 10 pharmacists with a range of different working backgrounds and age groups.  We attended a full day session every 4 to 6 weeks at the University.  We were relieved to discuss openly and share our experience on patient safety.  The aim was to build a safety case using our working environment and team resources.  My project centred on dispensing safety: ‘Are we dispensing safely?’ and later on was refined to a quantitative safety incident claim.

We were introduced to specific tools: Hierarchial Task Analysis (HTA), Failure Mode and Effect Analysis (FMEA), System Human Error Reduction & Production Approach (SHERPA) to help our analysis of the safety profile. Our team broke down the complex dispensing tasks into smaller working steps or processes systematically. On a practical application, the Proactive Risk Monitoring (PRIMO) questionnaire was helpful to use as a team to identify various patient safety risk factors.  We then made risk assessments of the dispensing processes through the SHERPA and used Plan, Do, Study, Act (PDSA) cycles to evaluate improvement.

The whole team began to monitor and record near misses and dispensing incidents on a more conscious level than before and made voluntary changes towards an open, no-blame working culture. The goal of safer dispensing became a number one priority all the times.  The team’s brainstorming revealed many common triggers or events of ‘the vulnerable moment’ during the dispensing processes.  Several checking procedures were used as checker reminders.

The pooled data of errors showed high times of errors, typical error categories and even the common medicines.  Individually, we were able to find out when and how we perform best and made aware of the pitfalls.  We discovered that we were prone to errors particularly when we were ‘expected’ to have ultra-quick dispensing.  Through a member’s suggestion and our dispenser’s effort, we now display a shop poster giving a summary of ‘the way we prepare your medicines’ and give customers opportunities to read through the additional copies whenever there is a queue forming.  It works really well and the feedback is positive too.  The team and customers seem happier.

In year 2 of the project, we came across analytical tools (Faulty Tree Analysis, Bowtie diagram) to look at our safety claim.  We continued to expand our safety interests and used a more sophisticated reporting form called  ‘Incident Investigation Form’ which covers error description, the factors causing the error, the risk category, course of the event and improvement plans.   We have since modified the form for in-house use.  The bundle of safety data showed how we had been dispensing safely or otherwise.  As a result, we implemented a couple of measures (such as safety shelf reminders, Top 20 common error medicines list) to help us improve on a regular basis.  The data is also useful in staff appraisal.

Moreover, we felt fortunate to have the ready-made patient safety data for Quality Payment application.  My experience in the patient safety collaborative has been overwhelmingly good and positive.  I wouldn’t have known about these analytical methods and thought about the improvement plans if I hadn’t been part of the study group.

I recommend that any pharmacy team who is interested should come along for a taster session to see if this is right for you.

Introducing…Safer Care Transitions

1 Jun

by Justin Waring (University of Nottingham) and Harm van Marwijk (University of Manchester)

Safer Care Transitions will be one of the research themes in the NIHR PSTRC Greater Manchester which will run from 1 August 2017 until 31 July 2022.

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Patient journeys are full of care transitions. By transitions, we mean that the responsibility for patient care is transferred or handed over from one team, department or organisation to another.

If we think about someone who experiences an accident at work, they might be seen at first by a paramedic before being transported by ambulance to their local hospital’s emergency department. There they might receive urgent care before being admitted into the hospital for follow-up care. When recovered, the patient will then be discharged home or to community setting where they could receive rehabilitation, nursing care, social care and follow-up treatments by their GP, under the primary medical responsibility of the GP.  The GPs’ medical records can follow most of such transitions and provide an overarching view, but others (patients) cannot access such data now. GPs would be seen to have an overarching responsibility to facilitate seamless management between settings but little work has been done on this.

Transitions are common to virtually all patient journeys, because healthcare services are provided by specialists and professionals who work in different clinics, surgeries and hospitals. Although there is now better understanding of what makes for safer care within each of these care settings, there is less of a clear picture about what makes for safer care transitions between these care settings, and how to develop problem-based records that capture transitions and are accessible to more than GP practices.

There is mounting evidence from around the world that care transitions are a high-risk stage in the patient journey. Research from the US, for example, suggests that as many as two out of every ten hospital discharges will experience some form of safety incident. These safety incidents take the form of incorrect medicines, missing equipment, or inappropriate care planning.  Research within the NHS suggests that it is often difficult to coordinate the involvement of different professionals and specialists because of common communication breakdowns and the difficulties of finding time to work together to identify solutions to common problems or work from a shared and validated record. A recent Healthwatch report highlighted the enormous suffering and anxiety experienced by patients as they approach hospital discharge, often because of the uncertainties about when they will go home, who will look after them, and how they will cope. Current resources constraints within the health and social care sectors have seemed to make these problems worse, with limits on the availability of social care to support safe hospital discharge.

The Patient Safety Translational Research Centre Greater Manchester is leading a programme of research that will develop new learning about what makes for safer care transitions. It will look to ways of working and technological breakthroughs in other sectors to learn lessons for the NHS. For example, many courier and supply chain services use advanced technologies to track their deliveries. There is also greater scope to empower patients to coordinate their own care through developing smart technologies that enable them to manage and share their own records with different healthcare professionals. There is also much healthcare services could learn from other industries about ensuring continuous accountability for care, so that someone is always there to speak up for and protect the safety of patients, and ways to develop such support for the most vulnerable trajectories such as around cancer and frail older people.

The projects developed in this theme will address the safety of care transitions in primary and secondary care, in mental health services, in chronic conditions, cancer care, and end of life care, to ensure learning and innovations are shared across the health and social care sectors.

Further information:

Healthwatch (2016) Safely Home, London: Healthwatch. http://www.healthwatch.co.uk/safely-home

Waring, J., Bishop, S., & Marshall, F. (2016). A qualitative study of professional and carer perceptions of the threats to safe hospital discharge for stroke and hip fracture patients in the English National Health Service. BMC health services research, 16(1), 297.

https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-016-1568-2

Forster, A. J., Murff, H. J., Peterson, J. F., Gandhi, T. K., & Bates, D. W. (2003). The incidence and severity of adverse events affecting patients after discharge from the hospital. Annals of internal medicine, 138(3), 161-167.

James Hind, member of the Community Pharmacy Patient Safety Collaborative, scoops Clinical Excellence Award at Superdrug’s annual Awards Ceremony

23 Feb

by Penny Lewis, Medication Safety theme

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James Hind, pharmacist and member of the Greater Manchester Community Pharmacy Patient Safety Collaborative, scooped the Clinical Excellence Award at Superdrug’s Annual Awards ceremony in Heathrow last week. The ceremony which aims to celebrate employees’ successes and achievements also marked 25 years of Superdrug Pharmacy. Other awards included Nurse of Year, Operational Excellence Award and Pharmacist of the Year (for which James was also nominated). James was awarded this honour after being recognised for his outstanding contribution to patient safety as part of his work with the Community Pharmacy Patient Safety Collaborative.

James, who has undergone training in risk assessment techniques and incident analysis as part of the collaborative, has shared his learning across the company via their online ‘Hub’. One of James’ innovations has been the design and production of bag labels to prompt both staff and patients to check their medications or ask any questions before leaving the pharmacy. James has conducted a survey to explore patients’ views of the label which has shown that the label is well received by patients and can, in some cases, prompt patients to take a more proactive approach to checking. James hopes to evaluate the impact of the label on patient safety incidents over the next few months.

James’s passion for improving patient safety engendered by his work with the collaborative has inspired James to work more closely with Superdrug’s Safety Office and also suggest improvements to their incident reporting system. James also noted that error reporting has increased threefold as a result of his participation in the collaborative and that his team are now far more reflective of their practice when things go wrong.

Well done James!

Read James Hind’s blog post on his involvement with the Community Pharmacy Patient Safety Collaborative here

What are patient and clinician priorities for research in primary care patient safety?

9 Dec

by Rebecca Morris, Research Fellow in General Practice theme

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Over the last few months I have been working on the James Lind Alliance (JLA) Primary Care Patient Safety Priority Setting Partnership (PSP) (to find out more about the JLA read Richard Morley’s blog ‘Welcome to the Revolution’). The aim of our PSP is to ask ‘what are the questions that patients and clinicians have about primary care patient safety?’ The final aim is to produce a list of the 10 top uncertainties (or questions) that need to be addressed by research.

What have we been doing? Anyone could submit their question about primary care patient safety to our survey which was open from June to mid-July for 6 weeks. We advertised the survey in many places with the support of our steering group, their networks, and other organisations to reach as many people as possible and we had a total of 443 questions submitted.  Thank you to everyone who took part! 

The next stage in the JLA process involved working through the list to categorise the questions into different categories and by the areas of primary care (eg pharmacy, general practice, dentistry, out of hours care, self-management or broader primary care questions).  Then we worked through the list of questions to combine duplicate or similar questions. This produced a list of 173 possible uncertainties.

What are we doing at the moment? We are currently searching the literature to see if these questions have been answered using the JLA criteria for a ‘certainty’. We have been working with Central Manchester Foundation Trust libraries that have been searching the literature and we have been reviewing the searches to see if any of these questions have been answered. Any questions not answered already will then form a list of ‘uncertainties’. There has been a great range of questions posed which has made very interesting to look through such a diverse spread of topics. The next stage is to work with our PSP to initial prioritise the list of uncertainties and then in January we will have another survey which will open to everyone to help us identify the top 30 uncertainties to take to the final workshop in March, 2017.

What’s next and how can you get involved? Thank you to everyone who has taken part so far or worked with us to identify the literature. It’s a fascinating project with lots of great questions being posed and shows how many important areas there are for primary care patient safety research. Now I want to pass it back to you to help us prioritise the key areas for primary care patient safety research from these questions so please keep your eye out for the next survey in January, 2017. Thanks!

To keep up to date with what is happening and find out when the next survey is open follow @JLA_PtSafetyPSP

Community Pharmacy Patient Safety Collaborative: Involving the Patient

18 Oct

By James Hind

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Over the last year I had made some contacts with the University of Manchester’s undergraduate pharmacy programme – offering student placements and assessing the first year OSCE examinations. The tentacles of the University email system must have decided that I’d be up for something a bit different – out of the blue I received an email about the patient safety collaborative and it looked like it would be a really interesting idea.

Patient safety was something that I felt I could benefit from being challenged about so I decided to contact Penny, and I’ve been part of the collaborative for the last 6 months. I’m the Pharmacy Manager at Superdrug’s Manchester city centre branch – I’ve been there for almost 10 years now, and one of the things that I’ve noticed over the years is the move toward a more patient-centered approach.

Concordance has replaced compliance; services are geared toward the patients’ needs,  and one of the things that struck me, having been involved in this initiative was how best to include the patient in the process of dispensing their prescriptions.

I thought about how I’d always been told that pharmacists are the last step between the doctor writing the prescription and the patient taking their medication, and I realised that this wasn’t really true – it’s patients who are the last step. They decide whether or not to take what we dispense to them, and perhaps our challenge is to involve them more, and in a more consistent way, at the point where we hand over their medication.

I developed the idea of label that could be attached to the dispensing bag. I wanted something that could be used as a quick check (have we got the right patient; did we tell them what their medication was for, and are they confident that they know how to use it). I also wanted it to give some of the ownership back to the patient – sometimes things go wrong, and could a label be used as a prompt for the patient, to give them the confidence to contact us if they were unsure about anything or if they felt there may have been a mistake?

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Part of the work of the collaborative is for the participants to make a safety case. It involves taking a critical look at the systems and processes currently in place and the types of near misses and incidents that are occurring. The challenge is then to identify any interventions we could make, put them into practice, and  evaluate them to see if they were successful or not.

I’m still working my way through this process. Being part of the collaborative though has already had a really positive impact on the way I work and the discussions that I have with my team. We’re recording a lot more near-misses, because we’re all now more aware of them. More importantly, we’re really trying to analyse why they’re happening and learn from them. Patient safety can only improve as a result.

Read part one of the blog series.

Read part two of the blog series.

Community Pharmacy Patient Safety Collaborative part two: Assessing safety

31 Aug

by Sarah Wood, Member of the NIHR Greater Manchester PSTRC Community Pharmacy Patient Safety Collaborative

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I heard about the community pharmacy patient safety collaborative about 6 months ago through an advertisement by Community Pharmacy Greater Manchester. As a community pharmacy operations manager with some previous research experience, I have a keen interest in assessing and improving the safety of the many processes in community pharmacy and learning from other industries and experts to do so. As such, I wrote to Dr Penny Lewis to see how I could get involved.  Since then I have been attending monthly training sessions at the University and trying out my new skills back at the pharmacy I work in.

One particular risk to safety that I am interested in are interruptions, such as the phone ringing or customers waiting at the counter. These interruptions are a common occurrence in community pharmacies and can lead to problems when they disturb pharmacy staff who need to focus on the task dispensing medicines accurately. As a result of my involvement in the collaborative, I have produced a safety case on interruptions in the dispensing process in one of my pharmacies and have also identified potential areas for future safety cases. The process of gathering the data, observing the pharmacy, consulting on safety issues with my colleagues and writing up the safety case has made me view company safety mechanisms completely differently. An example of this is how we record errors in community pharmacy: it’s easy to get caught up in how many errors are reported and why they are happening (obviously very important) but we don’t always look at what is best for our staff and which recording mechanisms are easier for them to use on a day to day basis – this is something I will be looking at in future.

The collaboration is also taking on more community pharmacy professionals and, as such, one of my colleagues, an accuracy checking technician, will be joining me in the production of the next safety case. This will be even more beneficial for our company as we can produce and compare safety across different branches.

In the next stage of the collaborative I aim to put together a business case for improving safety. There are obvious, clinical reasons for improving safety in community pharmacy but not much is known about the impact a lack of safety has on our business e.g. loss of customer confidence and possibly loss of custom. This is something I think the wider profession will be interested in and may encourage businesses to be even more proactive when addressing safety issues.

Read part one of the blog series.

Read part three of the blog series.