Complex working environment, not poor training, blamed for drug errorsBMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b5328 (Published 07 December 2009) Cite this as: BMJ 2009;339:b5328
All rapid responses
The landmark EQUIP study sadly revealed no great shocks as hospital
prescribing errors have been an overlooked issue for some considerable
time. As a senior pharmacist, independent pharmacist prescriber and an
acute hospital medication safety lead I concur with the authors that the
faults of the prescribing process however are multifaceted and need
multiple and multidisciplinary actions to remedy.
Inevitable human errors in prescribing can only be remedied by
changing the latent organisational conditions that allow them, such as
having a national prescription chart, but additionally 24/7 access to
electronic Summary Care Records and increased use of pharmacist
independent prescribers in unscheduled admissions could help reduce the
great problem of drugs omitted on admission.
I also personally support the view of Clinical Pharmacologists that
despite the increasing complexity of drug regimes in patients, with ever
increasing age and co-morbidities, there is generally not enough education
and practical teaching for medical students about safe and effective
prescribing. I would further suggest that a mandatory prescribing
competence element should be considered for the revalidation process of
all Health Professionals that prescribe.
With NHS pressures set to escalate the problem of hospital
prescribing errors is not going to go away and in my opinion this study
could be used as the impetus for Health Professional Regulators, the
Department of Health, Royal Colleges, Medical Schools and Hospitals to
take some positive unified action to reduce needless harm to our patients
in the future.
“Don’t find fault; find a remedy, anybody can complain” Henry Ford
I participated in the EQUIP study as one of the expert clinician panel members who assigned the potential harm of the detected errors
Competing interests: No competing interests