The Pharmaceutical Journal
Vol 279 No 7459 p18
7 July 2007

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Letters to the Editor

Medication errors

Error logs miss the point of good governance

From Mr P. Walton, MRPharmS

I notice that the issue of error logs, the cornerstone of governance where medication errors have occurred, has been discussed at the June meeting of the Royal Pharmaceutical Society’s Council, and that changes have been announced in a Law and Ethics Bulletin (PJ, 30 June, p781).

Graham Phillips, in his submission to the June Council meeting, condensed my arguments regarding the criteria for referral of errors to Statutory Committee (correctly) to be that I considered them to be laughable. I am grateful to Mr Phillips for raising the issues, and generating debate. I hope that he will now look at the above-mentioned LEB and instigate further debate by the Council.

I believe that the Society does not understand the fears engendered by error logs in individuals at risk and has made things worse by issuing this LEB. I believe that pharmacy staff are more concerned by any action that employers may take in response to logged error than any action by the Society.

When the precepts of governance were first being sold to the profession, they were done so in a way that showed how its implementation would be protective of staff, in that most errors are not of the individual but are multifactoral and simply blaming a member of staff for an error would no longer be good enough. Unfortunately the system of implementation of governance simply by means of error logs and the subsequent discussion misses that point entirely.

As far as the revised LEB is concerned, I have the following reservations:

• First, it is rather myopic, since errors often result from outside factors. My pharmacy had a computer that would only print forenames and surnames on any label, even when a middle name had been correctly entered into the patient profile. This caused potentially disastrous problems when members of families were only differentiated by middle name. I could not get this changed no matter how many times I telephoned my software supplier.

There are many other examples of factors in errors not being solvable at local level or by individuals. When a rectifiable cause of error is reported to a person or company that is in a position to correct the problem, and when no corrective action is taken, then there needs to be somebody with power to find out why and effect change.

• Secondly, the referral of errors is through the employing company. Error logs reside within the company where errors are made. It is possible that the company may use information that resides within those logs to decide on issues other than those for which they were intended. A company that needs to shed staff for instance might well attempt to make a case using error logs to decide who must go.

It is naive to believe that staff will be encouraged to use logs honestly when they could be used in that manner. If any of the identifiable factors in error reside with the employer they may well be much keener to remove members of staff who report them from the payroll. Whistleblowers will be so at their own risk.

• Thirdly, there is a huge time requirement for properly recording errors and predisposing causes. When working I was invited by Manchester Primary Care Trust to submit error logs on a large standardised sheet. It soon became evident that the form I was supposed to fill in simply informed the PCT that an error had occurred and how we had dealt with any aftermath.

I was extremely unhappy about this because I understood that the object of governance was to rectify underlying causes which were not being canvassed. Knowing that these forms could be subpoenaed in any criminal action many years after an event, and how soon details fell from memory, I told the PCT that I would not use the form, and started supplying a properly detailed description, which took at least an hour to compile.

• Fourthly, most error reports are not being looked at. In order to allay fears that errors may result in action by the Statutory Committee the LEB says that the error logs will not usually be looked at by the Society inspector. Surely governance should be about looking at any predisposing cause or pattern of error and to that end all logs should be looked at in order to discern any repeated pattern across pharmacies.

Names of those involved in errors are not important, but causation is, especially if there is a pattern. One only has to look at what happened to Ghislaine Brant in the Shipman case to know how important it is that the Society is aware of what is going on and is able to spot patterns. Individuals cannot see the wider picture from the confines of their dispensary, but inspectors should be able to do so. It is also important that inspectors know what sort of errors are occurring so that they can warn others across the profession of any new risks resulting in error that have become evident.

• Fifthly, the Society is still talking about single dispensing errors in the LEB. My views on this have been made known already (PJ, 5 May, p524).

Philip Walton
Manchester

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