"Policymakers need to work with healthcare professionals across the NHS to discuss the errors that happen, from the most common to the most serious, why they happen, the contributing factors and the ways to prevent them happening"
We need to rethink medical errors
Jeremy Hunt has said that he wants to crack down on the number of medicine errors that happen in the NHS.
As a pharmacist, I have made errors; I am fortunate in that there have been relatively minor and cause no harm to patients. However, I have heard several horror stories of pharmacists who have made serious errors, from giving someone the wrong medicine, to giving them someone else’s medicine.
There are some errors that should never happen, but it is worth remembering that all healthcare professionals have gone through years of training to prepare them for the jobs they take on. It is also worth remembering that all healthcare professionals are as human as the patients they treat. Everyone does something wrong at work sometimes. I don’t know any pharmacist who has not made an error.
However, did you know that up until very recently, a pharmacist could be prosecuted for making an error? When the Medicines Act 1968 became legislation, it was illegal for a pharmacist to dispense a medicine that does not meet the prescription it is given against. Now, after years of campaigning, new legislation has been passed that will protect pharmacists from prosecution.
However, pharmacists now appear to face trial by the media. In recent weeks, dispensing errors have become headline news, so the trial has gone from the courtroom to the television.
We need to create a culture where pharmacists are encouraged to report the errors they make, however minor or severe, without fear of a backlash. No pharmacist wakes up in the morning and intends to make a mistake with someone's medicine. I discuss errors I have made with my colleagues and friends; some are common and some are serious. However, because we are open and honest about it, we all learn from each other's mistakes.
When I was training to be a pharmacist, I had a conversation with my tutor as I was extremely anxious about making an error. She told me frankly that I would make errors in my career, but I should ensure that they are few, far between and minor. Ironically, that same day a patient came in saying I had given them the wrong medicine, and I had. I felt terrible and was frightened I would get in trouble. I didn’t and I still qualified, but the anxiety and fear of making mistakes is a matter that if not addressed, will result in healthcare professionals having serious mental stresses.
I recently watched a TV drama called “Trauma”, about a surgeon whose mistake resulted in a 15 year old boy who had been stabbed losing his life. Rather than come clean at the start about the error he made, he covered it up to protect his reputation. It wasn’t until the deceased boy’s father took matters into his own hands that the surgeon admitted his error. Now, this was only TV, but I believe this happens in real life as well (at least in pharmacy anyway).
Policymakers need to work with healthcare professionals across the NHS to discuss the errors that happen, from the most common to the most serious, why they happen, the contributing factors and the ways to prevent them happening. Pharmacists need to be free to do that without fear of being beaten with a proverbial stick. Furthermore, the trade unions and organisations that represent healthcare professionals need to change the issue of medicine errors from a blame game to understanding the circumstances in which errors happen, if we are ever going to have a frank discussion about medicine errors in pharmacy.
Morenike is a Young Fabian member. Follow her on Twitter at @MorenikeAdeleke
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