Things very rarely are as bad as they seem when a dispensing error happens. I get to see lots of different incidents of varying degrees of severity, and I can help in my role, put those into context for somebody. Everybody has to make their first incident and it’s an horrific feeling when you make your first patient safety error. It’s a horrible feeling when you ever make those, but certainly knowing that you’re not alone and that there are people, whether that be in your own organisation or peers in other organisations, or colleagues that you work with across LPCs, or however you liaise with other people. Everybody is there and everybody can be there for support. And you should reach out and use that support to help you, because everybody’s been in that position and everybody’s got something they can contribute to helping you deal with that.

It really starts off with thinking about them as a person, so making sure that they’re okay. Getting involved in a dispensing incident can be really upsetting and some people feel quite scared about it, irrespective of the severity of the incident. I firmly believe that nobody goes to work to make an error or to get it wrong, but being a pharmacist or a pharmacy technician, or any member of the pharmacy team, sometimes things do go wrong.

The other thing that I always think is important to ask them, is about how the patient actually is. And if they don’t know that, I encourage them to find out, because I think it helps; particularly as in the majority of errors, patients are actually fine. It’s still an error and this needs looking into, but the majority, fortunately, cause little if any harm. And that’s always reassuring to anybody who’s been involved in an incident.

Once you’ve actually found out how the patient is, I think it enables you to look properly at what happened, but in a slightly different way. So my focus, when I’m looking at incidents and helping colleagues with that, is to focus on the ‘report-learn-share-act- review’ wheel. And I always encourage them to think about reporting, when they’re doing the report, including everything, however small, because often it’s the small little bits that help you get to why it happened and what can be done about it.

And thinking about what could be done differently. So encourage them to use and reflect with the ‘five whys’ documents and with root-cause analysis, and lots of other tools that can be used. It doesn’t particularly matter which tool, it’s not prescriptive, helping them pick something that works for them. But it’s about thinking about what happened, why did it happen, and what can I do to prevent it happening again; what have I learned and how do I share that.

And by reflecting on your practice, that makes you a better professional and it makes it safer for other patients in the future. Individuals can take responsibility for that and also document it if they want, as part of their CPD. That way, something good comes out of it, it doesn’t undo whatever happened in the incident but there is a benefit to it. And that’s kind of my approach when I start dealing with incidents.

Absolutely not. And it’s not the incident that makes me think about the individual, it’s their approach that they take when an incident’s happened. So the incident’s the incident, but what matters to me is what they do about that incident, what care and compassion they show, what reflection they make, and whether they’re open and honest about what’s actually gone on. I encourage people to tell me or somebody in my team everything. I want to know that they’re taking responsibility for it and not thinking it’s everybody else’s fault, but actually trying to really put themselves in the patient’s shoes and think about what that means for that individual.

Incidents are never a person’s fault, it’s a set of circumstances. Often lots of factors can contribute to it, but by spending that time reflecting on it, then that’s how they get to that. It can influence how I think about it, if people are very closed to what’s gone on in an incident, start to blame other people, don’t want to take the time to reflect and think about it and clearly aren’t trying to learn about it. But the incident per se, is not what would impact my view. I want to know that all the professionals are being patient centred and really care and have a concern when something’s gone wrong, and genuinely want to learn from it.

If you’re worried about reporting incidents, what I’d say to you is: always report an incident. The consequences of you not reporting something are always, in my experience, far more serious than the incident its actual self. You owe it to yourself, you owe it to the patients, and you owe it to other people in your team, to actually report something and help yourself and other people learn from that.

I also find that reporting, particularly if it’s something that’s reasonably serious, can help you get closure because you know that actually you’re doing the right thing by yourself and by patients. But it helps you to learn from that, because ultimately you don’t want to have the same thing happen again. You are helping prevent somebody else being in that same situation, so by sharing that information, if you’ve been upset by an incident, you’d like to think that might have stopped somebody else feeling like you’re feeling, because we all feel bad when there’s an incident.

It’s about being a professional first. And you need to know that you’ve done the right thing, and if you’ve done everything that you can do to learn from it and by reporting it, then that’s what you want to do. You need to resolve it professionally and efficiently, and your patients and anybody else will respect you for that. 

I would always advocate report, report, report; you can never report too much. And nobody will ever think badly of you for their being a high number of reports. Good reporting is a great thing. The absence of reporting is not.