The NHS Patient Safety Strategy outlines how “a ‘systems’ approach to error considers all relevant factors and means our pursuit of safety focuses on strategies that maximise the frequency of things going right”. 

It is important to examine the system when things go wrong, as this helps to identify ways to address system-based issues, rather than focusing on the person or people who were involved.

In order to think about how community pharmacy fits into the wider healthcare system, consider the process of a patient ordering a repeat prescription, it being sent to their community pharmacy and it being dispensed.

In the diagram below, each arrow represents a potential conversation. In practice there may be fewer conversations than represented in this diagram or there may be more. At first, this process may seem simple but there are many potential communication channels to consider. Looking at systems in this way can help in identifying where community pharmacy fits in, considering how the teams’ actions impact on other individuals in the system and also how other people’s actions impact on community pharmacy.

Once you've completed this module, move onto:
Part two: Investigating incidents and causes
Part three: Safety culture
Part four: Reporting and analysis
Part five: Patient and public involvement
Part six: Huddles
Part seven: Making improvements to patient safety
Part eight: The second victim phenomenon
But be sure to click next to complete this module first.