Tag Archives: Medication Safety

Community Pharmacy Patient Safety Collaborative: Safety Initiatives

14 Jun

Chui Cheung photo

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.

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


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

Keep taking the tablets: part one

11 Apr

by Max Scott

Part six of the blog series “The desperate fight to be heard, and supported, when living with the invisible struggles of Multimorbidity”

Introduction to the blog series is here


Regular (daily) medications:

VENTOLIN EVOHALER 10 micrograms (µg) as needed

SYMBICORT TURBOHALER 200µg, two puff morning and night

LEVOTHYROXINE TABLETS 50 µg, one every morning

LEVOTHYROXINE TABLETS 25µg, one every morning

OMEPRAZOLE TABLETS 20 milligrams (mg), one morning and night

TESTOSTERONE GEL 50 mg, one sachet each morning

FLUOXETINE 40mg, by way of two 20mg tablets every morning

PRAVASTATIN TABLETS, 20mg, one every night


PREGABALIN CAPSULES 300mg, one at night (for sleep disorders)

PREGABALIN CAPSULES 150mg, one in the morning (for meralgia paresthetica and back pain)

CLONAZEPAM TABLETS, 0.5mg, progressing to 1mg tablet and to be gradually raised to 2mg, at night

FOLIC ACID TABLETS 5mg, one at night

Other (sometimes taken) medicines:

MICOLETTE MICRO-ENEMAS, approx once a week

PARACETAMOL TABLETS 500mg, one-two when needed

CO CODAMOL TABLETS 8/500mg, one-two when needed

CODEINE TABLETS 30mg, one-two when needed


DIAZEPAM TABLETS 5mg, when needed

ANUSOL SUPPOSITORIES, when needed (for haemorrhoids)

Various creams, intermittently, not regularly

So far in this series, I have concentrated on the many experiences and difficulties of living with multimorbidity, and somehow making sure that you are listened to, believed, and respected by medical professionals. By the very nature of the condition, professionals will be faced with a patient who is complex and will, more than likely, have conditions which are invisible to the eye, making trust that much more important.  I will continue on this theme in the future, but for this article I am going to focus more on an inevitable price to pay for having multimorbidity – and that is having to take multiple medications.

I am presently on thirteen regular daily medications for my varied health issues, and I have to take several more intermittently when the need arises. Let me explain some of the problems this can cause. Firstly, for me, the patient. Then (in part two) with the GPs and Consultants.

The Patient

The first of my present medications I ever took were my asthma inhalers, and I have been on these for longer than I can remember. Taking them became a way of life many years ago. Later, gastritis led to me taking Omeprazole. These were joined by the odd Diazepam here and there for anxiety, and sometimes I needed to use a nasal spray for rhinitis. All fairly straightforward at this stage. Then came my Pituitary surgery in 2005. Along with my life in general, that is when taking medications became more complex. I have included a list of my medications above but, to clarify, the ones I take as a result of my tumour removal/hypopituitarism are Levothyroxine 50 and 25 mg, Testosterone gel, and nightly injections of Genotrophin Growth Hormone. Hydrocortisone tablets have been needed on occasion, but this remains an ambiguity of extreme curiousness, which I shall raise again later in this blog. Such things as foot operations; pain from trapped nerves, osteoarthritis, slipped discs etc; and complex sleep disorders have all added to the list.

It’s not just about the amount of medications that I am now on, but the amount of tablets I have to take, when, and how. Remember, anyone who has seen any of my other blogs on here, I have short term memory loss, plus cognitive and executive disorders, which make it all the more easy to make mistakes. I have had to get various “Daily Pill Boxes”, example photo also included here, which should give you an idea of the sheer amount.

I mentioned a moment ago about making mistakes. Well, the drug companies do not make things any easier by manufacturing capsule shells, containing different medications, that look so similar. For example, two of my medications – one for my gastritis, the other an anticonvulsant medication also used for pain and sleep disorders – are both contained in a small, totally white capsule. How ridiculous, and potentially hazardous, is this?  This may be one thing when still in their original boxes (which, incidentally, chop and change their designs and colours so that you never build up a familiarity with them, often seemingly copying the packaging of other drug brands) but when separated into my “daily pill box” can become a nightmare…I have to put my strongest reading glasses on, to find some tiny dark lettering on one of them, and that is the only way I can tell these two, radically different, medications apart. So, basically, I am now on so many medications that just taking the tablets, at the right time, and making sure they are the right ones, has become an art-form all unto itself!

A final point in this part one, and it is a very strange one. One medication that I have not had to take following the Pituitary surgery has been Hydrocortisone, needed when there is a deficiency of ACHC, the hormone that stimulates the production of hydrocortisone by the Adrenal Gland. This hormone often does need to be replaced with patients who have had Pituitary surgery, and, as so much of the after-effects of my Pituitary surgery has been severe, life-changing chronic fatigue, it would have been logical to expect me to be deficient in this. But not so. That is until recently, when I had a series of blood samples taken later in the day than usual: after mid-day, when I am really beginning to flounder as my body and mind wind down towards my afternoon sleep.  THIS time, my hydrocortisone level was found to be very low, and an emergency phone call came that I must start taking hydrocortisone tablets IMMEDIATELY. Ahh, an answer to a problem, I thought. But no. A couple of weeks later, I had another series of tests, which astonishingly showed that I do NOT need to take Hydrocortisone after all. The last test was taken earlier in the morning than the other one. Relevant? Well, all I can say is that there are times like this when I begin to feel like a human guinea-pig!

NIHR Greater Manchester PSTRC Meet the Team – Jane Sarginson

18 Jan

The third in our NIHR Greater Manchester PSTRC ‘Meet the Team’ series introduces Jane Sarginson, Daphne Jackson Fellow in Medication Safety theme.

Jane Sarginson_Meet the Team

Jane Sarginson_Meet the Team_Page_1Jane Sarginson_Meet the Team_Page_2

World Suicide Prevention Day: Increasing awareness amongst pharmacists

10 Sep

by Hayley Gorton (@hayley_gorton | @meds_safety), PhD student in Medication Safety theme and Pharmacist

World Suicide Prevention Day_HGblog

Every year, over 800,000 people die by suicide, worldwide. Suicide is, therefore, a major public health issue which the World Health Organization are committed to reduce – a 10% reduction in suicide deaths is pledged by 2020 [1]. Today, 10th September 2015, is World Suicide Prevention Day. I tentatively suggest that surprisingly few people will have heard of this international awareness day and perhaps realise the contribution of suicide as a cause of death worldwide. Recently, I attended the 28th World Congress of the International Association for Suicide Prevention (IASP) in Montréal. Fantastic work was presented by researchers from different backgrounds and there was a real sense of community and camaraderie between these researchers who are striving towards a common goal. On realising that I am in a unique position as a pharmacist researching in this field, I reflected on the likely awareness of suicide demographics and risk factors amongst my peers. As pharmacists are often the front line of public health, I have taken it as my duty to raise awareness within my field. To begin, I have written an article aimed at pharmacists published online in the Pharmaceutical Journal, the journal of the Royal Pharmaceutical Society, website: http://www.pharmaceutical-journal.com/opinion/blogs/suicide-an-unspoken-public-health-problem/20069127.blog

If you, or somebody you know if affected by suicidal thoughts or actions, please seek help; Samaritans 0845 790 9090


  1. World Health Organisation. Preventing Suicide: A global imperative. [Internet]. 2014 [cited 2014 Sept 12]. Available from: http://www.who.int/mental_health/prevention/suicide/suicideprevent/en/ .



The Drugs Don’t Work – the importance of using antibiotics responsibly

26 Jun

by Christian Thomas, PhD student in Medication Safety theme

Antibiotic Guardian _Christian Thomas blog_June 15

This summer saw the Chief Medical Officer of the NHS, Professor Dame Sally Davies present at the annual Cockroft Rutherford alumni lecture at the University of Manchester. The theme of the lecture was ‘The Drugs Don’t Work’ and focused on the real threat that the misuse of antibiotic medication poses to patient safety both nationally and worldwide (view the full lecture). Antibiotic medicines work by killing or preventing the growth of bacteria. When antibiotic medicines are used inappropriately bacteria can fight back and become ‘resistant’. This can happen when we take antibiotics that we don’t need (such as for a cold which is caused by a virus), or when we don’t take antibiotics the correct way (such as not finishing the whole course of a prescription). When bacteria become resistant, antibiotics are no longer effective at killing them. This means that the drugs used to treat bacterial infections are less likely to work and that infections could get worse or be passed on to others. Bacterial resistance is a growing problem and over 23,000 people die each year from bacterial infections that are resistant to antibiotics (1).


1. Prevention CfDCa. About Antimicrobial Resistance 2013 [cited 2015 16th of June].

Before antibiotics were discovered, infections could often be life-threatening. Simple operations and procedures were more risky due to the infection risk, and as late as the 1930s people died from infections. Today, not only do we rely on antibiotics when we have an infection, many patients rely on antibiotics to survive including patients receiving chemotherapy, dialysis, organ transplants and caesareans. Whilst researchers are trying to find new antibiotics, little progress has been made over the last over thirty years. Therefore, it is very important that we do everything that we can to ensure that the antibiotics we have remain as effective as possible. Sadly, not doing so risks taking us back to a time where common infections and minor injuries pose a serious threat to patient safety.

There are many ways in which we can help to slow antibiotic resistance. One simple thing that we can all do is wash our hands thoroughly as this helps to stop the spread of bacteria. Other important steps we can all take are to use antibiotics only when they are deemed necessary by a health professional. We should not expect antibiotics to be prescribed for a common cough or cold, as these are more likely to have been caused by a virus rather than a bacterial infection. If antibiotics are given, we should make sure to finish the whole course, even if we are feeling better. Finally, we should never share antibiotics with friends or family or use leftover prescriptions. Visit the Antibiotic Guardian webpage for more information on antibiotic resistance and to pledge to become an antibiotic guardian.

Research Rookie finds her feet with medication safety

26 Sep

by Faith Mann, member of the Greater Manchester PSTRC Research User Group, affiliated to Medication Safety theme

Faith Mann blog photo_Sept 14

“Why on earth am I doing this? Whatever possessed me to apply for this?” Those were some of the thoughts running through my mind as I prepared to attend my first meeting of the RUG back in May this year. After almost three years of blissful retirement with no deadlines to meet, no meetings to attend and no blogs to write, I began to question why I had signed up to take part in anything as structured and potentially demanding as the RUG appeared to be. Yes, I was interested in and committed to the concept of patient safety, but was this going to be a good use of my time, and could I really make a positive contribution to the work of the RUG?

Those doubts began to evaporate in the course of the meeting. The established RUG members warmly welcomed the three new members, of whom I was one, and the Chair of the meeting took the trouble to explain the background and import of some agenda items that would otherwise have been bewildering to a newcomer. Most importantly, the meeting ran to time! At the end of it I felt that I had gained a good understanding of the RUG and how it relates to the research themes and I was beginning to see how I could make a contribution to its work.

I was pleased to be aligned with the Medication Safety theme because some members of my family have suffered from mistakes in prescribing so I’m powerfully aware of the need for health professionals to maintain high standards in the prescribing and dispensing of medicines. Likewise, I believe that the patient has a responsibility to check prescriptions and to take medication according to the doctor’s or pharmacist’s instructions, so there is work to do from both the health professional’s and the patient’s perspectives.

There’s a lot happening in the Medication Safety research theme and I’m still in the process of getting to grips with it all but, already, I’ve been able to assist with identifying some patient focus groups to be interviewed for the research about their experiences with medication and I’m involved in the planning for an event that will highlight the issue of medication safety as part of the Manchester Science Festival. I feel that I have been welcomed by the research theme lead and the research assistants and that my perspective as a member of the public and occasional patient is valued by them.

It seems to me that PPI is still a fairly new concept to the NHS and is something that is put into practice to different degrees across the organisation as a whole. That’s one of the reasons why I applied to join the RUG in the first place – so that I could take part in the debate and help to develop a better understanding of the benefits of PPI and the opportunity that it presents for a true partnership approach between patients and health professionals which can only lead to better understanding between those groups and better outcomes for service users. I’m looking forward to the next couple of years to see how the RUG, of which I’m now a part, will influence health services across Greater Manchester, and possibly beyond.