Our Just Culture in Patient Safety

A message from Marc Donovan, Chief Pharmacist:

As pharmacy professionals and pharmacy team members, it’s vitally important that we create the right culture when it comes to patient safety. We need to ensure that our culture sets a clear standard and expectation of what it means to deliver safe and effective care to our patients and be confident in the systems that we have.

To ensure the right approach to patient safety, we must act when things go wrong.  Firstly, we must record accurately what went wrong – either via a Near Miss Log or via PIERS, as applicable. This is essential, and a habit that all of us must attain. I require you to record all patient safety events. Without open, accurate and transparent recording of operational safety matters, we cannot improve. 

Secondly, we must ascertain what went wrong. This is a fundamental part of any patient safety culture. I need you to review the reports created in your pharmacy regularly to understand and consider why any shortfall(s) in patient care occurred and whether any wider system issues are involved. My team and I do the same and we look for trends and insights so that we can implement changes and ensure that any systematic shortfalls that have led to sub-optimal behaviours or actions are understood and addressed.

I want to continue to lead for a culture in which we all learn from our mistakes and where inadvertent human error, freely admitted, is not subject to disciplinary action so that we can improve safety and care for others. Of course, we will continue to hold people to account if there is evidence of gross negligence, as that is an important part of a ‘Just Culture’ too.

To support your further understanding of our ‘Just Culture’, please complete the relevant Boots Learning package for your role. Further information about this eLearning requirement is provided in the Patient Safety First article.

Patient safety involves much more than ensuring that errors do not happen. Patient safety should be holistic in its approach, ensuring that the purpose, benefits and potential risks of any medication supplied are understood by the patient; that an opportunity is provided for the patient to ask questions; and that the medication prescribed is right (optimised) for their needs. We must continue to lead for a ‘Counsel Culture’ and always see the patient behind the prescription, to enable us to achieve all of the above effectively.