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Letters to the Editor
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Statutory Committee
Disciplinary procedures
From Mr H. A. Lockie, MRPharmS
A reprimand was issued to a pharmacist who made one significant error
in 30 years of practice and several correspondents have commented that
praise and a medal were more appropriate.
If professionals did not care about their errors, a reprimand could make
a difference by frightening others into being more careful. But this is
rarely the case. Most errors are due to a combination of circumstances
caused by system faults. Improved patient safety comes from openly admitting
to errors with no fear of retribution, so that the causative factors can
be recognised by others early enough to avoid a repetition. As it has been
pointed out, the aviation industry does this to great benefit.
Unfortunately, a reprimand by the Statutory Committee has exactly the opposite
effect. The committee appears to be required to punish faults, without
apparently being required to take into account the wider requirement of
preventing errors. Such a structure is in itself a system fault that guarantees
continuing errors.
One can either have a system that punishes occasional human faults, or
a system that improves patient safety, not both.
Harvey Lockie
Auckland, New Zealand |
The
Pharmaceutical Journal