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Letters to the Editor
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Medication errors
Reply from
Jackie Giltrow, chief inspector and head of regulatory transition,
Royal Pharmaceutical Society
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Has there been a review?
From Mr P. Walton, MRPharmS
In a previous letter (PJ, 7 July 2007, p18) I complained that Royal
Pharmaceutical Society inspectors ignoring error logs so that pharmacists
felt free to report errors missed the point of good governance, and that
they should only be used to discover the root causes of system errors
and not to make pharmacists feel threatened.
In a reply (PJ, 21 July 2007, p72), Graham
Phillips stated that there would
be a review of the situation in six months.
I would like to know whether this review was ever undertaken. Error logs should
be used to remove or reduce the main causes of error and collated information
should be used to warn pharmacists of new threats which are causing problems
so that pharmacists can avoid getting themselves into career- (or even freedom-)
threatening situations.
It seems to me that blaming people when something has gone wrong is far easier
than preventing things from going wrong in the first place, which is the route
our professional bodies and legal system have taken.
I am heartily sick of
the platitudes (rather than action) that have destroyed my belief in protecting
myself by operating good governance protocols and procedures. Philip Walton
Manchester
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JACKIE GILTROW, chief inspector and head of regulatory transition,
Royal Pharmaceutical Society, responds:
The Society supports and encourages
the maintenance of medication error logs as part of clinical
governance arrangements.
Error logs are intended to be used as a risk management tool and information
from the logs should be regularly reviewed, analysed and discussed within the
pharmacy in order to identify risk areas. Appropriate action to review systems
and procedures with a view to minimisation of future risk should be taken, where
necessary.
During inspections, Society inspectors may ask to see evidence that
systems are in place to deal with dispensing errors, including the maintenance
and use of medication error logs.
Inspectors will seek to ensure that there are satisfactory internal processes
to audit and analyse the errors made and for remedial action to be taken if
appropriate.
Pharmacists are advised to participate in local, employer
and/or national reporting systems to ensure that trend analysis can be undertaken
with a view
to encouraging wider learning.
If the Society receives a complaint about a dispensing error, the inspector
may, as part of the investigation, ask to see the specific error log which
relates
to the complaint under investigation and to seek to identify the root cause
analysis of the error.
As part of the Society’s review of the use of error logs in cases involving
single, one-off dispensing errors, a consultation on “threshold criteria” has
been launched (PJ, 9 February 2008, centre pull-out section).
(PDF 380K)
Full details of the consultation can be found on the Society
website.
The closing date for the consultation is 18 April 2008 and the maintenance
of error logs is specifically mentioned as evidence of good practice and
one of
the reasons for non referral of a pharmacist to the Investigating Committee.
Cases of dispensing errors that are not referred are dealt with by
way of guidance and advice to pharmacists to ensure that steps are taken to reduce
the likelihood of similar errors occurring.
The consultation is indicative of the Society seeking to ensure that proportionate
action is taken in such cases in order to serve the public interest. |
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The
Pharmaceutical Journal