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To err is human, to learn divine

More needs to be done so that health care professionals can learn from, anticipate and eliminate medication errors. In this week’s Journal we carry features about medication errors caused by the misreading of labels or packaging (p286) and about reporting and analysing medication errors in general (p287).

Misreading the packaging on medicines, leading to the dispensing of the wrong product or strength, is a common source of error. This has been compounded in recent years as each pharmaceutical company has strived to bring all of its products into a single corporate style. As a result, many of the packs are virtually indistinguishable, particularly when large ranges of generic products from the same supplier are placed close together. Since these packs are designed and approved individually the problem is not immediately apparent outside a typical pharmacy.

An expert group established by the Committee on Safety of Medicines has recommended that all medicinal products should carry a standardised “number plate” of product information in a prominent position. This will undoubtedly make checking that the correct product has been selected easier, but care will be needed to ensure that the number plate format does not lead to an even greater homogenisation of packaging design. Perhaps, the Medicines Control Agency needs to look at how new pack designs will fit into the real world of busy pharmacies and crowded medicine cabinets, not just whether they meet approved standards when considered alone.

One major problem with medication errors at present is a lack of formal reporting programmes at anything other than the level of a single hospital or organisation. Research has shown that the same errors are repeated over and over again. National reporting schemes are needed so that patterns can be established and warnings and guidance disseminated to all who need to know, not just those involved in individual errors. For these schemes to work there has to be an effective no-blame culture. Anyone who thinks that they will be suspended from duty or disciplined if they report an error might, quite naturally, keep quiet, whatever the consequences for patient safety. A no-blame culture can only be established if it is accepted that errors do occur. Media reports of “medical blunders” and knee-jerk management reactions to these reports prevent this happening.

The Government is establishing a National Patient Safety Organisation. One of its first tasks must be to pursuade the public that a confidential reporting system is designed to protect patients not those making the reports. Unless errors are reported and analysed, no lessons can be learnt.

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