PCT phase (Pre-CCG)

Responses

Of the 146 PCTs contacted, 27 (response rate, 18.5%) completed and returned the

questionnaire. The low response rate may be attributed to the imminent changes within the structure of the NHS at the time of the survey. The most relevant change was the abolition of PCTs with the formation of general practitioner-led CCGs on April 1^st 2013; as such, many roles within local health authorities were changing. Also at the time, some PCTs were operating as clusters such that two or more PCTs had a joint Head and/or Department of

All (10) the then Strategic Health Authorities (SHA) of the NHS were represented, with Yorkshire and The Humber having the highest response rate (18.5% of all responses). The

“current role” as stated by respondents widely varied – eleven different titles were used, the most frequently occurring being Head, Medicines Management (33% responses). The average “number of years in role” of the respondents was 6.1, ranging from 6 months to 12 years. However, most respondents (81% responses) had held related roles for more than 5 years. Most respondents (85% responses) were aged over 40 years, with 48% of respondents being over 50 years.

Categories of incidents classed as prescribing or dispensing errors:

Twenty-three categories each of prescribing and dispensing errors were identified following analysis. The most frequently occurring categories included wrong drug, dose, patient, strength, direction, formulation and quantity for both prescribing and dispensing errors. The least frequently mentioned categories for prescribing errors included omission, duplication, reconciliation, prescribing outside local guidance/tariff, prescribing on repeats without checks and excessive prescribing, and for dispensing errors, dispensing without prescription,

dispensing in the face of known allergies, and missing patient information leaflets (PIL).

Mode of receipt of critical incident data from general practices and community pharmacies by PCTs:

PCTs mostly received critical incident data from general practices and community

pharmacies through spontaneous reports from third parties, and occasionally from general practices and community pharmacies on ad hoc bases. Such third parties included patients (often as complaints), hospitals (during admissions), other healthcare professionals (such as practice reporting a dispensing error), and through the NPSA database. Only three PCTs requested periodic incident reports from general practices and community pharmacies bi-monthly or quarterly. General practices and community pharmacies were also able to submit error reports anonymously in which case PCTs could not follow up. Organizations

(community pharmacies in particular) are also able to report errors via their own reporting systems. Another commonly occurring theme was in relation to controlled drug (CD) error reporting – ten PCTs mentioned that as a legal requirement, it was mandatory to report all CD

errors unlike other incidents. In addition to CD errors, a few PCTs mentioned that all “serious incidents” such as “death”, “press-relevant”, “serious consequences”, were to be reported by general practices and/or community pharmacies as soon as they are made aware of them.

General practices are also able to report via DATIX®-web⁴, which feeds directly to the National Report and Learning System (NRLS) of the NPSA. Prescribing incident information is also captured occasionally through ePACT⁵ prescribing data under the Quality of

Outcomes Framework (QoF).

Frequency of collation of critical incident data from general practices and community pharmacies by PCTs:

The themes in responses were: following spontaneous error reports from general practices and community pharmacies, from third parties, and via the NRLS, PCTs collate incident data from general practices and community pharmacies monthly (3 PCTs), quarterly (mostly CDs, 2 PCTs) and at least annually (3 PCTs). Others collate reports “as and when” i.e. following occurrence and on an ad hoc basis.

Existing protocols by PCTs for general practices and community pharmacies to manage critical incidents:

PCTs were also asked if they had any existing protocol for general practices and community pharmacies to identify, record and report critical incidents. The responses to this question were very varied. Only one PCT appended a full protocol to their response: following an error report, PCTs commonly request significant event analyses, SEA or internal event analysis, IEA, or root cause analysis, RCA for serious untoward incidents, SUI. Other responses include the use of standard operating procedures (SOPs) and practice prescribing policies for managing critical incidents. Other themes, which occurred in response to this question, included provision of many avenues to report serious incidents to PCT (telephone

4 DATIX is the leading supplier of patient safety software for healthcare risk management, incident reporting software and adverse event reporting www.datix.co.uk

5 ePACT is an application, which allows nominated users at PCT or Trust or National level to electronically access prescription data. It allows real time on-line analysis of the previous sixty months prescribing data held

call, letter or email, use of online voluntary reporting, DATIX, NPSA, own system), contract monitoring, RCA, use of standard forms for reporting CD errors, the use of policy documents relating to error recording and reporting, use of prescribing protocols or algorithms, reporting systems in care homes, and learning from errors and prevention. Two PCTs reported they had no existing protocols.

Existing systems within PCT to review critical incident data:

While 3 PCTs (11%) answered no, most PCTs (92%) answered yes to having existing systems to review critical incident data within their medicines management departments.

These include practice or pharmacy follow-up by medicines management to ensure corresponding action is taken, discussion of case summaries, SEA/RCA, interrogations of data captured, investigations of practices or pharmacies, facilitated discussions at prescribing lead meetings, dissemination of learning points with primary care providers, analysis of safety trends, and dedicating an incident team to work with and support pharmacies/practices.

Collation of “near miss” incidents from general practices and community pharmacies:

17 PCTs (17; 63%) did not collect “near miss” logs from general practices or community pharmacies. Of the 10 PCTs who collected “near miss” data, most of them did so at irregular intervals; three PCTs, however collated “near miss” data annually “as part of contract

monitoring” procedures. One PCT, which collated “near miss” data, noted that “it is hard to define a near miss” in their response.

Existing PCT interventions to prevent medication incidents in general practices and community pharmacies:

Lastly, PCTs were asked about the interventions they have implemented to prevent

occurrence of medication incidents within general practices and community pharmacies. One respondent mentioned that no interventions had been implemented “as far as they were aware”. Two PCTs did not answer this question. Therefore, 24 PCTs (88%) mentioned one or more interventions; these included issuance of prescribing and dispensing policies and

updates, shared learning, development and dissemination of newsletters, raising awareness of common incidents via memos, letters, “learning from reporting” bulletins, annual safety audits of prescriptions of high risk drugs in practices, altering GP computer systems on security access and formulary, SOP, updates through ScriptSwitch, reviews of service level agreement, contract monitoring, reporting concerns to the General Pharmaceutical Council (GPhC), inspection visits, and contractual sanctions and warnings.

The most important data from the PCT study are summarised below Questionnaire survey enquiries PCT responses (main themes) Mode of receipt of critical

incident (CI) data by PCT from Primary Care Organisations, PCOs (general practices and community pharmacies)

Most PCTs received information through spontaneous reports from general practice

Frequency of collation of CI data from PCOs by PCT

Most PCTs collated or reviewed information on “as and when” bases.

Existing PCT protocols for PCOs to manage their CI data

Practices follow their own prescribing policies and practices may report via DATIX-Web

Existing PCT systems to review CI data from PCOs locally

Most PCTs agreed that they had systems in place. These comprised internal reviews of incident data, completion of Significant Event Analyses (SEA) and Root Cause Analyses (RCA) for Serious Untoward Incidents (SUI) by practices or pharmacies with support from PCT medicines management, PCT reviews and

recommendations with action plansx Collation of near miss incident

reports from PCOs

PCTs did not often review near miss logs from PCOs PCT interventions to prevent

medication incidents in PCOs

Shared learning practices, periodic issue of newsletters highlighting trends in incidents, use of education memos such as “Learning from Reporting Bulletins,” policy guidance development and reviews, review of service level agreements.