The Pharmaceutical Journal
Vol 277 No 7422 p450
14 October 2006

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· E-commerce
· EPS
· Pfizer products (3)
· Drug misuse
· Pharmacy ownership
· Statutory Committee
· The profession
· Superdrug
· Retention fee
· Job satisfaction

Letters to the Editor

Statutory Committee

Unfortunate impact of decision on error reporting systems

From Mr A. J. Jukes, MRPharmS

With regard to the dispensing error concerning pergolide (PJ, 16 September, p353) I have significant concerns with the outcome following the Statutory Committee decision since it will have implications on whether people would be willing to report errors in future. Non-reporting of errors would affect the value of education and improvements to work systems and practice, therefore increasing the risk to patients. I would make the following observations:

· Everyone (pharmacists and technical staff) can make errors due to a variety of co-factors: high workload, low staffing, multiple distractions, poorly developed work systems and practice, and individual factors that sometimes have to be addressed by the staff member concerned.

· The drug involved in an error and the dose or frequency inaccuracy alongside patient factors, such as age, etc, will determine a particular outcome or consequence. However errors with starkly different outcomes can arise through similar root causes. If the error were 50mg atenolol instead of 50mg amitriptyline in identical livery then this would have a different set of root causes and outcomes from the pergolide error. My point is that we should learn from the individual root causes and circumstances that may pertain at the time. At the time of the pergolide error, what were the circumstances? It is only by reporting, analysing and improving that scenarios like these can be minimised in future.

· Many of us will have made errors. I have, and I have learnt from them. I have shared the knowledge with colleagues and reported errors via internal incident reporting systems so that, through education, future errors may monitored or prevented.

In my view, the Statutory Committee ruling jeopardises the attainment of an “appropriate blame” culture, whereby members of staff making mistakes can admit to it and share the knowledge. A fear that they may be reprimanded or struck off may serve to facilitate a return to the dark days of blame and under-reporting, increasing risk. This is not the way forward for the profession or ultimately patients.

Andrew Jukes
Brighton

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