Under-performance within the health service has been attracting a great deal of attention recently. So much so that the Department of Health set up an expert group on learning from adverse events. That group has now reported (see p898) and the main thrust of its recommendations is that a mandatory scheme should be introduced by the NHS Executive to ensure comprehensive reporting of adverse events and near-misses in NHS health care settings. Clearly, such a recommendation, which has been accepted by the Government, will help to ensure that trends and clusters of error are spotted and suitable remedial action put in hand. Pharmacists will want to play their part in this and will have plenty of scope for making suggestions, since the report is not prescriptive in relation to finding solutions to problems.
But the report, perhaps by virtue of the group's terms of reference, smacks of shutting the stable door after the horse has bolted, or several horses in the case of clusters and trends. Just as much attention, if not more, should be placed on setting up safe systems of work in the first place. With medicines being one of the most frequently used of medical interventions, pharmacists must have a part to play in this. In America, this is being recognised by proposing that pharmacists provide a pharmaceutical care role within the Medicare federal health insurance programme for the elderly (PJ, June 10, p885). In Britain, pharmacists aspire to equivalent types of input, but their aspirations are constrained in the hospital setting by severe staff shortages (PJ, June 10, p866) and in the community by lack of Government provision for new practice models, such as medicines management/pharmaceutical care. Pharmacists must be allowed to realise their potential.