Abolishing the blame culture
Few people have any doubt that errors are unreported in the health service and a paper in the BMJ reveals the scale
may be even greater than suspected (p761). The decision by the Government to overhaul
the error reporting
system developed via the National Patient Safety Agency and to refocus
the agency’s activities means that patient safety is going
to be further up the agenda in 2007 (p761).
Add to this the decision made by the Council of the Royal Pharmaceutical
Society earlier this month that the Society will seek to have dispensing
errors decriminalised (16 December, p723 and p753) as well as giving
Society inspectors the responsibility of sorting
out minor problems at a local level (p773) and error reporting rates may start to go up in
the future.
Although many health professionals are weary of the comparisons made
between their activities and those of people working in the air and oil
industries, the stark truth is that until managing mistakes in the health
service becomes a transparent process and people learn from each other’s
lapses without fear of admonishment or retribution there is unlikely
to be much improvement in the number of errors that occur.
It is human nature to keep quiet because, if someone makes a mistake
and does not admit it, he or she may get away with it; coming clean,
however, may involve the individual in all sorts of bother. Just ask
any politician, journalist, accountant or lawyer! Why should the world
expect health professionals to behave any differently? Their duty of
care to patients and their professionalism should make them respond differently,
although clearly many of them do not — otherwise many more errors
would be reported.
The Journal welcomes any initiative that will lead pharmacists and other
health professionals to admit to all mistakes — “honest” as
well as “careless” ones. Being open and willing to discuss
problems with other health professionals will be a start in ridding the
health service of its current blame culture.
As 2006 draws to a close and 2007 is no longer a distant time, we hope
that all pharmacists will consider making a resolution to manage any
errors they may make in a better way next year.
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Merry Christmas and a Happy New Year!
It is hard — looking back on 2006 — to typify the year in a few words or phrases. In this week’s News
feature (p764) we have gathered together
some of the low points (such as the oxygen debacle) and highlights (the launch
of independent prescribing). In a sense, it was a year of consolidation and of
waiting for things to happen. Next year should see more progress on a number
of fronts. In the meantime, enjoy the holiday period and join us again on Twelfth
Night!
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