The Pharmaceutical Journal
Vol 268 No 7196 p611-613
4 May 2002

This page
Reprint
Photocopy

PDF* 65K

  CPD
  Clinical governance
  Checking technicians
  Community pharmacy
  The Profession
  Council elections
  The Society
  Society fellows
  PJ Online

Letters to the Editor

Clinical governance

There but for the grace of God

From Mr S. A. Reeve, MRPharmS

Every pharmacist knows the sickening realisation of making a bad mistake. You agonise about what to do, what to say, whom to tell. Later, the event replays itself over and over in your mind. You become the "second victim" as described by Wu.¹

Being involved in an error or patient injury is extremely distressing but it is the attendant feeling of guilt or remorse and the desire to prevent it happening again that makes you a true professional. However, the very existence of this error damages your professional self-image.

Medication errors are a fact of life. Errors are not all due to the individual. They can arise from poorly designed procedures, premises or systems. These are "errors waiting to happen" — critical incidents. Refinement of our procedures, processes and systems is one aspect of clinical governance. Planned improvement will minimise errors. Well-trained staff, clear procedures and a safe environment are essential. Early recognition of poor standards, decisive intervention, effective self-regulation and feedback on performance and error reporting, are all part of the clinical governance process.

The question is, are we up to it? When given the opportunity to help and the barriers of shame and blame of punishment are removed, then pharmacists will eagerly work to improve the safety of their patients, and will be in a position to help others to minimise the chances of error occurring.

"Local champions" — individual pharmacists — can, by their enthusiasm, motivate others to make improvements. However, major system changes require direction from the top — leaders to communicate their commitment, and that of their organisation, to their fellow pharmacists.

A system of "no blame" error reporting is a start to this process. Communication of ideas to prevent errors, for example, not relying on memory, not using out-dated literature sources, using computer generated standard prescription doses, redesigning patient packs, segregating oral anti-diabetic medicines, and separating "look-alike" patient packs within the dispensary.

When errors occur, we should learn and prevent rather than blame and hide. It is time to channel attention to our error-prone health care systems. We need to learn from failures and spread good practice. Let us talk about it.

Stuart Reeve
Clinical Governance Lead Pharmacist,
Leeds Health Authority

Previous Topic (CPD)
Next Topic (Checking technicians)
Send your letter to The Editor