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Letters to the Editor
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Dispensing errors
What use is reporting dispensing errors if nothing is then done?
From Mr P. Walton, MRPharmS
The Royal Pharmaceutical Society wants to have dispensing
errors decriminalised in order to encourage their reporting (PJ, 16 December 2006, p753).
What use is the reporting of errors and their cause when nothing is done
when
the reports are submitted, unless there is a direct political imperative
such as in the wake of Harold Shipman?
Five years ago I made as much noise as I could about a series of, lethal
if dispensed, prescriptions we received (10 in a month when audited). Nobody
wanted to know then or even now, although the cause still exists and it
has been
re-reported to the authorities recently.
I also doubt if it is criminalisation of errors that prevents them being
reported; it is more likely the probability that reporting error is likely
to upset employers. I know of pharmacists who walk into conditions that
are impossible to work in safely. They may make errors or have near misses,
but do not complain or report them because, if they did, they could find
it extremely difficult to work again in their area.
Does anyone really believe that if a lethal dispensing error is made there
will not be criminal proceedings?
About five years ago I went to a branch meeting on governance conducted
by an employee of the Society. At the time I found it difficult to elicit
answers about the supposed introduction of a “no/fair blame culture” which
made real sense. Five years on and we seemingly have not got any further
with respect to the framework required for governance to create improvement.
It is educational to attempt to create change in response to error. Part
of the reason my partners and I sold our pharmacy last year was that we
believed edicts from those agencies that govern the way we operated (including
the Royal Pharmaceutical Society) were making our operation much more dangerous,
frequently putting us in a position where error occurred or was extremely
likely to occur, and nobody wanted to know or investigate.
Philip Walton
Manchester |
The
Pharmaceutical Journal