Points to note when using the framework
It’s important to start to ask ourselves:
5 weeks later patient X requested a further supply of mycophenolate 500mg tablets. The practice pharmacist was asked to generate the prescription but noted that no blood results had been recorded since starting the mycophenolate. Patient X had also not attended their appointment with the phlebotomist 1 week earlier. The pharmacist also noted that the NPT template for new start patients was not completed.
The Lead GP and the practice pharmacist agreed that no further prescription for mycophenolate were to be issued until patient X attended for bloods. Subsequently blood monitoring weekly appointments were booked for patient X and a prescription for mycophenolate was issued 1 week later.
It was agreed that the incident would be discussed at the next GP practice meeting and that a Significant Event Analysis (SEA) would also be undertaken.
Further assessment – using the measurement and monitoring of safety framework
The practice pharmacist contacted the Lead Pharmacist in Forth Valley to discuss the incident and to highlight the agreement that a serious event analysis (SEA) was to be undertaken.
In the usual circumstances these actions would have been sufficient i.e. the patient incident was resolved, the incident would be shared and discussed at the GP practice meeting and an SEA would be undertaken to identify key learning points.
However, due to a local programme to test the framework for the measurement and monitoring of safety, the Lead Pharmacist questioned the practice pharmacist further by asking:
The practice pharmacist then subsequently discussed with the Lead GP for the practice and implemented the following actions that same day:
The SEA was completed and a number of key learning points were identified and addressed, as well as the above three points identified by the practice pharmacist: