“Knowing” is not “doing”
There cannot be a pharmacist, doctor or nurse in the country who does not know that errors are made in the prescribing, supply or administration of medicines. What is more, avoiding errors does not require a degree in rocket science. Nevertheless, systems are not always put in place to avoid mistakes — despite guidance and warnings.
A report published this week by the Department of Health makes parallel
points. At one level there is nothing new to say about how to avoid medication
errors and yet they still happen. As Professor David Cousins, head of
safe medication practice at the National Patient Safety Agency, points
out (p80), “knowing” about something is not the same as “doing” something
about it.
A case in point is the storage of potassium chloride. In July 2002 the
NPSA issued a patient safety alert asking that all concentrated forms
of potassium chloride be removed from wards and the drug treated in the
same manner as Controlled Drugs. An audit carried out by the NPSA revealed
that only 25 per cent of acute trusts had complied with the guidance.
There have been previous suggestions that a typical response from those
reluctant to comply is “Well, we have never had a problem”.
Many of the lessons being employed in patient safety are taken from the
experience of the airline industry. Only this week Flight International reported that the number of crashes worldwide in 2003, involving commercial
flights, was the lowest since records began in the 1950s, even though
traffic growth exceeded 40 per cent.
As a result of 27 fatal accidents out of a total more than 50 million
aircraft movements, 702 people were killed. This should be salutary reading
for anyone involved in patient care, and is evidence that when everyone
acts on known risks, the results can be impressive.
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Off the record
One of this year's editorial innovations is an occasional series entitled Off
the record. Our first contribution can be found on p99. Readers are invited to contribute either 400- or 600-word items about some anecdotal aspect of pharmacy practice that they think is worth sharing. It might be a lesson from a patient,
an incident that made them laugh or cry, or something they were told by another
health professional that has influenced their practice.
Although items will be published anonymously, contributors must give their full
name and address in order for their pieces to be considered for publication,
and we reserve the right to abridge them.
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