The Pharmaceutical Journal Vol 267 No 7165 p347-351
15 September 2001

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Medication errors

Don’t always believe what you read

From Mr A. J. Nunn, FRPharmS

Dr John Pickup should have sufficient experience of inaccurate media reporting to check the facts before linking a press report about Alder Hey Children’s Hospital to his justifiable criticism of colour-coding in relation to the prevention of medication errors (PJ, 8 September, p321). The Pharmaceutical Journal should keep to its policy of sending letters “critical of individuals, organisations or companies ... to the person or body concerned, so that they are given a simultaneous right of reply”. To the best of my knowledge neither Dr Pickup nor The Journal has checked the facts and I have not been contacted to allow a simultaneous reply which could have avoided yet more unwarranted adverse publicity for this hospital.

I can assure colleagues that Alder Hey is not using colour-coded syringes as inaccurately reported on the BBC News web page. I can also state that we do not support colour-coding as a means of identifying medicines but that we do use colour to emphasise warnings or dangers. This is in keeping with the report of the labelling and packaging working group referenced by Dr Pickup and illustrated by the example of labels for potassium-containing injections bearing a large letter “K” in red.

Pharmacists and other professional colleagues at Alder Hey are hard working and proactive in their efforts to prevent medication errors. We make use of the reports from a computerised database of errors and near misses spanning eight years. We run a multidisciplinary group which reviews all reports and recommends and implements remedial action. We carry out medication error potential analysis on new drugs and we are actively engaged in developing prevention strategies with colleagues in the North West.

The implied criticism of Alder Hey is inaccurate and unhelpful. By way of redress Dr Pickup and a reporter from The Journal should visit Alder Hey to examine and report our wide ranging attempts to prevent medication errors. This could provide a positive contribution to the debate and be far more useful than a belated apology.

Tony Nunn
Director of Pharmacy,
Royal Liverpool Children’s NHS Trust

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