Urgent action required to improve patient safety and professional reputation

Hemant Patel, Secretary for the North East London LPC, has written to NHS England, GPHC, RPS, PSNC and Pharmacy Voice to improve patient safety by reducing picking errors in community pharmacies.

Begin forwarded message:

From: Hemant Patel
Subject: Unacceptable and requires action to improve patient safety and professional reputation

Dear Colleagues

I’m both saddened and angry after reading the story below which shows that avoidable errors which require action are harming patients and reputation of the profession. In the story below, a pharmacist is blamed for being ‘over-tired’ without a mention of significant contributory factors which contributed to the trajectory error.

Two potent drugs made by the same manufacturer should not be looking alike or packaged in boxes that look alike. MHRA needs to be pressurised to take immediate action to prevent errors due to look-alike tablets and containers. This is not the first incidence of its kind but I am amazed that good packaging guidance is continually ignored by manufacturers and MHRA.

Branding is important to companies and I understand that. But, responsibility for such safety should extend beyond the drug and include packaging.

Bruce Warner, who is copied into this email, worked hard when at NPSA to improve safety. I’m sure he would be equally appalled and concerned as us. I have provided s link below.

There is a company (Almus) that does take a need to improve patient safety by improving packaging yet strongly retaining a brand identity. (http://www.almus.co.uk/design-concept).

In the case below, I believe a case can be made for contributory negligence against the company manufacturing the product as the error and consequences are both predictable and they have failed to fully appreciate the logistical situation of the pharmacy where supply of their product would be made.

Community pharmacists work is difficult and is made more difficult by lack of sufficient  care and by manufacturers to improve safety and by MHRA, a government agency responsible for ensuring that only safe products enter the supply chain in the U.K.

The available error described is likely to be repeated again many time unless the manufacturers, MHRA, wholesalers, and pharmacists revisit this topic urgently and insist on colour and design differentiation on packaging which is essential for improving patient safety.



Why do we blame Pharmacist Fatigue when fatal errors are originating from poor design & outdated tools? | mHealth Insight

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As yet another completely avoidable death is being blamed on Pharmacist Fatigue surely it is time we scrapped the idea that human judgement is perfect and handwritten scrawlings on scraps of paper are safe.

We shouldn’t tolerate a situation where Amazon pickers use better tech (to post me books) than Pharmacists use to dispense my lifesaving medications. It’s time we made Pharmacy’s responsible for adopting the tools of our time because there aren’t any Community Pharmacists left who don’t have smartphones (supercomputers in their pockets) capable of providing a machine reading safety stop.


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