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Error reporting and duty of candour

13 November 2014

According to data published in August by the Health & Social Care Information Centre, although the NHS received 60,000 written complaints last year about GPs and dentists, the number of complaints against pharmacists was insignificant.

However, there must have been more patient safety incidents than pharmacies are reporting to the National Patient Safety Agency.

The NHS terms of service have for a long time required the reporting of all patient safety incidents. But pharmacies have reported on average fewer than one per pharmacy. 

If we assume that each pharmacy encountered more than one error a year, it follows that errors are being under reported even, though pharmacies have until now been free to report incidents anonymously to avoid the risk of prosecution or fitness to practise proceedings.

As part of the new NHS funding deal announced recently by the PSNC, pharmacies reporting incidents will in future have to identify themselves.

However, they will only have to report incidents that did or could have led to patient harm. Near misses, such as picking errors that are identified and corrected during checking procedures need not be reported.

The NHS believes improving error reporting will show patient safety is at the heart of pharmacists’ work, but the right of anonymity will be removed “to allow easier shared learning”.

I do not see how taking away the right to report errors anonymously will allow other pharmacists to learn from the mistakes of others.

There is no right to avoid self-incrimination, so requiring pharmacies to identify themselves is more likely to discourage error reporting at a time when the NHS is trying to improve it.

Allied to the subject of error reporting, the GPhC has recently put its name to a joint statement by all statutory healthcare regulators on the requirement for a duty of candour. 

Although this key theme of the Francis Report is not yet enshrined in law, the regulators say every healthcare professional must:

  • tell the patient when something has gone wrong
  • apologise to the patient
  • offer an appropriate remedy (if possible), and
  • explain fully to the patient the short and long term effects of what has happened.

I believe this is the right way forward. I would like NHS England to be open and honest, and admit that taking away the opportunity to report patient safety incidents anonymously is likely to be counter-productive.

This article was written by David Reissner.

For more information please contact David on +44 (0)20 7203 5065 or david.reissner@crsblaw.com