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PRACTICE: Vikas Chadha, Iain Cruickshank, Robert Swingler, and Roshini Sanders Advanced glaucomatous visual loss and oral steroids BMJ 2008; 337: a670 [Full text]

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Improving individual and organisational learning from adverse drug events

Alison L Cracknell   (26 November 2008)

Improving individual and organisational learning from adverse drug events 26 November 2008
Alison L Cracknell, SpR Elderly and General Medicine Leeds General Infirmary, LS1 3EX Send response to journal: Re: Improving individual and organisational learning from adverse drug events	I read with interest and sadness the case report of Chadha et al describing visual loss as a consequence of high dose steroids (1). The authors successfully raise awareness of this adverse drug event, relevant to a wide audience; as many clinicians will prescribe high dose steroids for a variety of conditions with limited prior knowledge of this a potential serious consequence. However I feel the case can provide an even greater opportunity to promote how clinicians should learn from adverse events, as regrettably more often than not we do not reflect and consider altering practice as a result. This was an adverse drug event with tragic consequences for the patient, whether preventable or not there are wider issues that need discussing. Every doctor has a duty to review and reflect on their practice as a result of an adverse event or near miss, whether preventable or not. I am certainly not an expert in the management of temporal arteritis, but I would promote practitioners reflecting on this case; whether this was preventable or not and whether their practice in similar cases would be different next time. There may be no lessons to learn but issues to be discussed should include: a)is 60mg prednisolone an appropriate starting dose in a patient presenting with GCA with no visual symptoms? b)is tapering the dose from 60mg to 25mg over 7 months reasonable? c) although an infrequent in speciality practice, perhaps this is not as uncommon in ophthalmology departments? Therefore how are we going to promote awareness of this issue (e.g national reporting of adverse drug events, multi-departmental adverse event review or morbidity meetings). This case may not have been preventable, and I am in no way criticising the management. I am just advocating reflective practice and feel by avoiding discussing the above issues we continue to promote the culture that adverse events are inevitable. However hard it may be we all need to become more comfortable discussing and reflecting on our practice as a result of patient safety incidents. It is only by senior colleagues championing this approach in front of junior doctors (in an open, non- judgemental reflective manner) that the culture of learning from adverse events will steadily change, and perhaps more will be prevented. references: 1. Chadha V, Cruickshank I, Swingler R, Sanders R. Advanced glaucomatous visual loss and oral steroids. Competing interests: None declared