The Pharmaceutical Journal
Vol 280 No 7499 p506
26 April 2008

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• White Paper
• Patient records
• Electronic prescribing
• Pharmacy contract
• Community pharmacy
• Medicines use reviews
• Minor ailment scheme
• Medication errors
• English Pharmacy Board
• Council election
• Education
• Public relations
• New professional body
• The Society (2)
• Euthanasia (2)

Letters to the Editor

Medication errors

Error reporting system is problematic

From Mr P. Walton, MRPharmS

I would like to thank Jackie Gilrow for responding to my previous letter about error logs (PJ, 5 April 2008, p398). I had seen the consultation document on non-referral to the Statutory Committee, which refers to one-off dispensing errors, even though the average three-year error rate would be in the order of 500 (see previous letters from myself, Joy Wingfield and Graham Phillips [PJ, 16 June, 2007,p717]).

In the Shipman case, Ghislaine Brant could have made an excellent defence case that she did not realise that Shipman was overprescribng diamorphine because she worked in a single location with no outside view of what is normal. The Royal Pharmaceutical Society inspector who signed the register every six months would have seen many registers for comparison, and he did not notice problems. A similar situation should exist with error logs.

However the scheme highlighted by Ms Gilrow would not achieve that because it only operates within the bounds of the pharmacy where the error has occurred. It is dependent on the employer or pharmacist participating in local or national reporting systems to externalise any problems.

Where problems are caused by the employer this reporting mechanism is probably useless. How many complaints are surfacing of errors attributable to understaffing and would the Society expect employers to incriminate themselves by citing understaffing as a cause of error?

In the case of an error where a pharmacist needs evidence that there was a problem that remained unresolved despite being reported, the Society system would not help. Where an error only occurs rarely then cross pharmacy knowledge is probably essential to prevent occurrence elsewhere, as it is unlikely to have occured at that pharmacy in order to be evaluated.

The error reporting system we have only gives a strong audit trail up to the pharmacist or technician who dispensed the item and protects those above by having a weak trail. An examination of the situation in the peppermint water case may help to elucidate this contention.

Philip Walton
Manchester

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