Record interventions as near misses, says CHI
Pharmacists’ prescribing interventions should be recorded
as near miss medical errors, according to the Commission for Health Improvement.
The CHI report of a clinical governance review at
North Glamorgan NHS Trust, comments on steps taken by the trust to review
medication errors — drug incidents, as the CHI calls them. It says that
pharmacist-monitoring of prescribing often results in changes being made
before medicines are given to patients, but that these changes are not
recorded in any structured way and are not considered to be near miss
incidents.
“The trust needs to review how the important information
from this intervention is aggregated and analysed so that learning can
be spread across all clinical teams,” the report says. Dr Bryony Dean,
director of the academic pharmacy unit at the Hammersmith Hospitals NHS
Trust, agrees that recording and monitoring pharmacy interventions is
necessary as a learning exercise.
“Doctors really don’t seem to be very aware of the
errors they have made,” she said. You can look at pharmacy interventions
as a defence, she says, but it is a mistake to treat pharmacists as though
they are infallible and to rely on them picking up doctors’ mistakes.
“Feedback to prescribers has got to be helpful in
terms of raising error awareness. It’s a valuable opportunity to feed
back and make all health professionals aware of the sort of things that
go wrong and what can be done to prevent them,” she added.
Back to Top
|
