Better systems should be adopted to identify and eliminate errors

Drug errors are avoidable but difficult to avoid. The prescriber has to be knowledgeable enough to choose an effective treatment suitable for the individual patient, taking into account age, infirmity, and possible interactions with other drugs. Having selected the right agent and the correct dose, the prescriber has to transmit the message to the dispenser, who has then to hand the drug to the patient or to a carer or nurse, who has to see that the drug is given in the correct way and at the specified times. The process is complex, and, not surprisingly, errors occur. Their frequency is difficult to estimate. As with air travel, deaths are sufficiently rare that “near misses” are important. More important still is to devise a strategy for reducing errors.

Bates et al have recently reported a study from Boston in which they identified about 6.5 actual and 5.5 potential adverse drug events—errors or adverse reactions involving drug treatment—per 100 hospital patients.1 Over a quarter of the observed events resulted from errors, and these were generally more serious than the adverse reactions. Drug errors are clearly an important cause of morbidity in hospital2 3 4 and probably in general practice. …