The Pharmaceutical Journal
Vol 268 No 7204 p903-905
29 June 2002

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Letters to the Editor

Medication errors

Need to look at other industries

From Mr T. Delaney, MPSI

The Daily Mail of 18 June 2002 proclaimed on its front page: "And now: the great hospital blunders cover-up". Small wonder then, that your leading article (PJ, 22 June, p860) should express frustration about the way the news media portrays hospital errors.

Since 2000, with the support of the Irish Department of Health & Children, my hospital has been running a medication safety project. We conducted a staff survey, with over 500 responses from nurses, doctors and pharmacy staff, which identified why people did not report medication errors. These were: fear of ridicule and blame by peers, fear of punishment by management, and cynicism because of a perception that reports were used solely for bureaucratic purposes, and not to learn from mistakes and make improvements.

We now employ a full-time drug safety co-ordinator to investigate incidents, identify systematic causes and make recommendations for changes to our medicines use systems when they fail. With wide consultation with all staff groups, medical defence bodies and a patient advocacy organisation, we have developed a system-based, non-punitive medication safety incident reporting policy that is currently being rolled out. We have seen a 20-fold increase in the number of incident reports being made by staff. We have conducted several root cause analyses and instituted system changes to prevent errors happening again.

Our programme has received widespread and regular coverage in the national media in Ireland. One problem with newspapers is that whereas journalists conduct interviews and write articles, they do not write headlines. This is the task of sub-editors, who feel the need to attract the reader with dramatic language. Thus we have had articles headlined "100s get wrong pills at Tallaght" and "Drug errors scheme leads to fears for patients". Despite these headlines, the articles beneath were generally balanced and fair.

As you said in your editorial (PJ, 22 June, p860), "People working in the health service do not deliberately set out to make mistakes and harm patients." This is true, but it is no comfort to the family of a patient who has been permanently harmed or killed by a mistake. It is human nature to become defensive when criticised, but we must not let that lead us to delude ourselves about the seriousness of the problem. 

Your leading article points to systematic causes of error saying that "health service staff often work long hours under considerable pressure to provide good care". Those in leadership positions in the system are responsible for this and it is not acceptable that we set individuals up for error through overwork. 

You rightly said that "people need support and encouragement, not derision and vilification". This is undoubtedly true, but it is the nature of the support that matters. Support can take the form of empty words of encouragement or empathy, or it can take the form of active measures to correct the system-based causes of error.

As a first step to this, the health system needs to adopt the principles and methods of quality improvement which have transformed performance and greatly reduced error in other industries.

Tim Delaney
Head of Pharmacy & Director of Accreditation,
The Adelaide & Meath Hospital Dublin,
Ireland

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