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Published on 9 August 2013

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RPS responds to report “Improving the safety of patients in England

The RPS warmly welcomes the publication of Professor Berwick’s report, and believes his call for quality of patient care to be placed above all other aims will be welcomed by pharmacists.
The RPS agrees that a safer NHS will depend upon major cultural change, leadership and a learning culture across the system and we are pleased that much of our existing work on ‘professional empowerment’, ‘just culture’ and ‘quality systems’ resonates with the key messages within Professor Berwick’s report.

The RPS warmly welcomes the publication of Professor Berwick’s report, and believes his call for quality of patient care to be placed above all other aims will be welcomed by pharmacists.
The RPS agrees that a safer NHS will depend upon major cultural change, leadership and a learning culture across the system and we are pleased that much of our existing work on ‘professional empowerment’, ‘just culture’ and ‘quality systems’ resonates with the key messages within Professor Berwick’s report.
The report has clearly set out the importance of removing the toxic culture of fear to achieve safety and improvement; the benefits in trusting the goodwill and intentions of staff; that the tiny number of cases that involve wilful or reckless neglect or mistreatment deserve censure, but that errors are not misconduct and do not warrant punishment.
English Pharmacy Board Chair David Branford said: “Pharmacists know that patients and the public are exposed to risks every time they choose to take, or not to take, a medicine. Alongside adverse reactions, side effects and toxicity sit risks of non adherence and under treatment. Quality for pharmacists is about optimising the care of patients through better, safer use of medicines and one that pharmacists have championed across the NHS”.
This is the leadership role pharmacists have within the NHS, if they work in hospitals, community, primary care or research settings. Don Berwick’s key recommendation for continual learning and improvement of patient care to be the top priority for the NHS is supported by our development of the RPS Faculty.
We have set out the following priorities for action:
  1. Embed the concept of quality within pharmacy. We are developing a resource for pharmacy professionals that will provide insight, knowledge and perspective into quality systems for pharmacy. This will help pharmacists at all levels to play their part in improving the ‘quality of patient care’.
  2. End the barriers to learning created by fear of the automatic criminalisation of dispensing errors.
  3. Ensure system regulation by both the pharmacy regulator GPhC and the Care Quality Commission  supports the creation of an environment where pharmacists can prioritise safety and quality above commercial or process targets
  4. Encourage company policies, senior managers and leaders to focus on the quality of patient care, patient safety and patient centred professionalism above everything else.  Make this the custom and practice that prevails across the whole of pharmacy.
  5. Ensure staff have the capability, and organisations have the capacity to meet the challenge of healthcare needs now and in the future. The RPS Faculty has been created to ensure individual pharmacists can be the “best they can be” for patients. Our current work on Hospital Pharmacy Standards and in future Community Pharmacy Standards are designed to support pharmacy organisations to meet their core responsibilities around the provision of safe and effective care.
Success in these areas means that the RPS must work in partnership with patients, the profession, regulators, Government and pharmacy organisations. Don Berwick’s report gives added impetus to all of us to ensure we are doing everything we can to keep patients safe and ensure the quality of their care is as high as it can be through pharmacy.


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