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In this fourth article on aspects of clinical governance, Catherine Dewsbury (the Royal Pharmaceutical Society's clinical governance pharmacist) looks at the way in which clinical governance affects the individual pharmacist and the need for an open approach to investigating the causes of error in the interest of patient safety |
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It is not always easy to be a professional
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What do I do when I have tried to do what is right and it still goes wrong?In an earlier article in this series (PJ, 15 December 2001, p873), I said that clinical governance is about doing the right thing right to the right people at the right time. On millions of occasions every day it is easy for pharmacists to practise in this way. For example, on receipt of a prescription, the pharmacist reads it and establishes that it is legal, that the dose prescribed is appropriate and that the drug is suitable for the patient. Then someone types the label, assembles the product and the pharmacist checks the product against the prescription. Finally, the medicine is supplied to the patient (or the patient's representative) and there is a short discussion on how to take it. Job done. At other times it can be more difficult. An example is the patient needing a cocktail of medicines for symptom control in palliative care. Sometimes, although there is little research on whether the drugs can be mixed in the same syringe, the nurses or doctors looking after the patient want to give the drugs together so as to minimise the number of injections. In these circumstances, what is right pharmaceutically and what is best for the patient? Does the pharmacist have time to ring the manufacturers, to ask colleagues, to contact a few specialist centres or to put a request to a medicines information service? Or, has someone already mixed the medicines and administered the injection? Has something already happened to the patient and the doctor wants to know whether the mixture caused the problem? Are you the central intravenous additive service manager being asked to make up the syringes for storage and use elsewhere? The answer may depend on the medicines, on the actual question being asked, on the circumstances, on how much time the pharmacist has to look into the research and on what information is available. However, even with plenty of time and all the published information, the pharmacist may still find that there is no answer to the query — so what does he or she say? It is not always easy to be a professional This is what being a professional is all about. It is not always easy. For any query there may be more than one answer or no answer at all. It is up to the pharmacist to give the best advice available and to be accountable for the advice given. This is clinical governance. Guessing is not an option: people expect and deserve better than that. Clinical governance is about knowing one's limitations and/or the limitations in the research. One will need to be honest with one's colleagues, with the patient and with the patient's family, analysing the risks, minimising them and agreeing a course of action — acting in the interests of patients, as is required by pharmacy's Code of Ethics. What happens when something goes wrong? According to Department of Health documents, community pharmacies in England dispense more than 550 million prescription items in each year and hospital pharmacies dispense half a million items a day. To these figures one can add the advice community pharmacists give to the two million or so people who consult them every day, the advice each clinical pharmacist in our hospitals provides to professional colleagues about dozens of patients each day, and the day-to-day advice that pharmacists working as pharmaceutical advisers or public health specialists provide to clinicians responsible for providing health services to the nation. With pharmacists supplying so many medicines and so much advice, it is inevitable that, at some time, in some part of Britain, something will go wrong for a patient or a group of patients. I have yet to meet a pharmacist who has never been involved in such an incident or a near miss. Any practising pharmacist who has never been involved in a near miss or a mistake is extremely lucky, and the rest of us wish to know the secret. In 2000, a report by the Chief Medical Officer, "An organisation with a memory", found that 10,000 hospital patients each year have serious adverse reactions to medicines and that one-fifth of clinical negligence litigation stems from hospital medicines errors. There are no robust figures for community practice because many — perhaps most — incidents are dealt with at the pharmacy level. Many hospital pharmacies and pharmacy chains already have systems for collecting information on errors, and are in various stages of developing systems for recording near misses (see, for example, the paper by Oborne al, PJ, 26 January, p101). All these systems rely on individual pharmacists or staff members sending reports to head office. Recording incidents and errors is best practice for all pharmacists, including independent contractors and locum pharmacists. However, some professionals are more willing to report incidents than others. I hypothesise that most of us are afraid of making mistakes. Each time we make a mistake someone could be hurt. Professionals do not as a rule set out to harm people but, like everyone else, they are human and can suffer from illness, stress and even addiction. Mistakes happen even without human error. Working conditions can and do contribute to errors. No-one can function at their best if they work extended hours without breaks, with insufficient support staff, or in working conditions that are not conducive to minimising risks. When incidents do occur, it is important to investigate the causes and learn why they happened. This does not override one's responsibility to the person affected by the incident. To get to the bottom of why an incident has occurred needs an open approach. Honest and accurate accounts of what happened, including the working conditions at the time the incident occurred, are vital if similar incidents are to be prevented in the future. Every major incident is a potential learning experience for professions. This is why all health care providers, including pharmacies, need to develop a no-blame culture when investigating incidents and errors. This does not mean that professionals who have been careless, negligent or deliberately criminal should get away with it. That would be a blame-free, rather than a no-blame, culture. What it does mean is that professionals who have done everything in their power to do the right thing, who have kept up to date and were working in the interests of their patients, should be encouraged to report and discuss the incident in the interest of protecting future patients. This sort of no-blame approach contributes to future patient safety. It contributes to the memory of the profession (or organisation). This is clinical governance. It is a brave new world, but it is one that we all need to embrace. |
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