CPD activity

Before you start reading this article, think about:

• What do I want to learn? 
• What will I gain from this learning?
• What will my employer gain?
• What difference will it make to people who use my services?

Sometimes, mistakes get made and things go wrong in pharmacy. Part one of this module covered what can go wrong but what is equally important is how teams learn from those situations, which is the focus of this module.

You may be familiar with the terms ‘adverse event’ and ‘near miss’ to describe errors in pharmacy. These are now all defined as ‘incidents’. Situations where harm is avoided (i.e. a near miss) are called ‘no harm incidents’. The National Reporting and Learning System (NRLS) uses the following approved particulars to classify incidents:

• No-harm
• Low
• Moderate
• Severe
• Death.

These are subject to change; information of which can be found via PSNC.

It is important that incidents are reported to the NRLS so that the whole of the NHS can learn from past incidents and prevent future occurrences.