The Pharmaceutical Journal
Vol 270 No 7239 p325
8 March 2003

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National Patient Safety Agency (www.npsa.org.uk)

Safety alert prompts makers to offer range of potassium chloride dilutions

Manufacturers of potassium chloride solution have pledged to provide whatever dilutions the National Health Service requests, following the patient safety alert that came into effect at the end of October 2002.

Professor Rory Shaw, chairman of the National Patient Safety Agency, which is currently auditing the effectiveness of the alert, said that this would be a helpful contribution towards ensuring the safe use of potassium chloride.

Professor Shaw was speaking at the launch of a discussion document "Creating the virtuous circle", an initiative sponsored jointly by the NPSA and the NHS Confederation, and designed to create an open and fair culture in which NHS staff will no longer be fearful about reporting errors and near-misses.

Professor Shaw gave a parallel example from the oil industry when, before a blame-free reporting system was introduced, 15 divers died in the Norwegian sector in 1975 alone but since then, between 1992 and 2002, there have been no deaths.

Professor Shaw pointed out that this endeavour would involve individuals and their representatives, NHS managers, regulatory bodies and medical royal colleges, as well as other bodies involved in the inspection of the health service. The media and politicians also needed to be aware that patient safety would only improve when mistakes were perceived as an opportunity to learn rather than a finger-pointing exercise. The regulators of the health professions had a distinct role in learning to distinguish between honest mistakes and instances where an individual had deliberately violated the rules.

Professor Shaw also said that the reporting of errors and near-misses should be made as easy as possible. The reporting systems themselves should be designed to protect individuals from blame and, whenever possible, reporting should be local so that local solutions to problems can be established.