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Medication safety

Pharmacy practice has improved 'significantly' since the Gosport tragedy, says new guidance

New resource emphasises the significant progress made in pharmacy practice, while urging pharmacists to further engage with patient safety.

ash soni rps annual general meeting 18

Source: Royal Pharmaceutical Society

Ash Soni, president of the Royal Pharmaceutical Society, encouraged pharmacists to “support a culture of patient safety in all care settings”

The pharmacy profession has “moved on significantly” since the events at Gosport War Memorial Hospital which led to the deaths of hundreds of patients, new guidance has said.

A new resource published jointly by the General Pharmaceutical Council (GPhC), the Royal Pharmaceutical Society (RPS) and the Association of Pharmacy Technicians UK (APTUK) has outlined the ways in which the profession has improved since 450 people died at Gosport between 1989 and 2000.

The Gosport Independent Panel’s report, published in July 2018, found no evidence that pharmacists had challenged prescribing practices at the hospital, which included inappropriate anticipatory opioid prescribing. 

The three pharmacy bodies are calling on all pharmacists and pharmacy technicians to read and discuss the 24 presentation slides published on 13 February 2019, which “emphasise that pharmacy practice has moved on significantly since the terrible events at Gosport”.

They state that under the current systems there is a “clear framework in place for providers of pharmacy services” including RPS standards for hospital pharmacy services, which were first published in 2012 and “set out what’s expected of a quality service”.

The slides also note that pharmacists today are “more prepared to challenge poor practice and behaviours”, while “tighter controls” now govern the use and management of controlled drugs since the Harold Shipman case.

Nigel Clarke, chair of the GPhC, said: “Pharmacy practice has now moved on significantly since the terrible events at Gosport took place; all professionals are expected now to speak out under the duty of candour when there are issues or things have gone wrong, and we underline the importance of learning and reflection.

“We would urge everyone across pharmacy to consider the presentation and discuss what this means for their practice with other professionals, students and support staff.

“Pharmacy professionals should also consider using this resource for their reflective accounts or peer discussions as part of revalidation.”

Tess Fenn, former president of APTUK, added: “Since the significant failures at Gosport Memorial Hospital, the role of the pharmacy technician has evolved exponentially.

“Pharmacy technicians are now an important component of frontline pharmacy care and are often the first point of contact for patients and the public in both hospitals and community settings.”

Ash Soni, president of the RPS, added: “The lesson for everyone is to encourage and support a culture of patient safety in all care settings.”

The RPS also published a report on 5 February 2018 which said that the inappropriate use of opioid drugs at Gosport could have been identified sooner if electronic prescribing had been in place at the time.

Citation: The Pharmaceutical Journal DOI: 10.1211/PJ.2019.20206156

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