Reporting of errors should be free of recrimination

BMJ 1995; 311 doi: https://doi.org/10.1136/bmj.311.7016.1367a (Published 18 November 1995) Cite this as: BMJ 1995;311:1367
  1. D R Upton,
  2. D H Cousins
  1. Pharmacy services manager Glenfield Hospital NHS Trust, Leicester LE3 9QP
  2. Head of pharmacy Derbyshire Royal Infirmary NHS Trust, Derby DE1 2QY

    EDITOR,--We support R E Ferner's sentiments regarding errors of prescribing.1 There is a profound need for strategies that manage such errors by reviewing systems rather than by apportioning individual blame. Hopefully, the recent papers in JAMA, cited by Ferner, will stimulate debate on drug errors and encourage this process.

    For several years we have campaigned for multidisciplinary medication quality assurance groups to be established in NHS hospitals.2 These groups should aim to create a non-threatening environment in which all staff who prescribe, dispense, and give drugs feel able to report adverse incidents voluntarily, free from fear of recrimination. Reporting may be anonymous if this is thought appropriate, but in our experience staff are commendably forthright in adding their name to completed records, which aids the identification of individual training requirements. Completed reports are reviewed regularly by the quality assurance group and recommendations are made to all staff as to how future risk can be minimised.

    Audit criteria set out by the King's Fund include requirements for the monitoring of prescriptions and the management of error and other risk related to dispensing and the administration of drugs. We would like to see the position strengthened such that the existence of a formal system of reporting errors, subject to multidisciplinary review, becomes a condition for the accreditation of NHS hospitals.

    These steps will enhance the management of risk associated with giving drugs locally, but what of the national situation? We have provided a facility for colleagues to report incidents that they regard as important and that contain a valuable lesson for future practice2; uptake has been encouraging. In addition, many reports are published anonymously and debated in the pharmaceutical literature.3 Could a similar system be coordinated nationally by the Committee on Safety of Medicines? A process analogous to the system for reporting adverse drug reactions could be adopted to facilitate the reporting of errors of prescribing that result in appreciable morbidity (or, indeed, the reporting of near misses that narrowly avoided causing harm). As with the yellow card scheme, the compilation of reports on a nationwide database would alert the regulatory bodies to particular problems in the safe use of drugs. This in turn would permit national initiatives aimed at minimising the potential harm to our patients from the treatment with which we intend to do good.


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