Abstract
Aims and MethodA new medication error reporting scheme (‘Safemed’) was introduced within the East Kent NHS and Social Care Partnership Trust. All medication incidents reported using this system in the first year were analysed by the Chief Pharmacist.ResultsOver a 12-month period a total of 66 incidents were reported through Safemed, compared with 55 incidents under the previous system. The low level of reporting made detailed statistical analysis and drawing meaningful conclusions problematic. There was a large variability in reporting between similar sites.Clinical ImplicationsThe low level of reporting was associated with cultural factors, in particular the failure to fully implement a ‘no blame’ culture. Until such a culture is established, reporting will remain variable and a systems approach to preventing medication errors will not be adopted, leading to significant clinical risk.
Highlights
Medication errors are a major cause of injury and occur in 2-15% of hospital admissions (Leape, 1994; Bates et al, 1995)
The National Patient Safety Agency was established by the Department of Health; one of the roles of this agency is to collect and analyse medication errors and ensure that practice is modified (Department of Health, 2001)
A substantial number of publications on medication errors in general (Bates et al, 1993; Dean & Barber, 2001; Dean et al, 2002; Koren, 2002; Bumpus & al-Assaf, 2003; France et al, 2003; Howard et al, 2003), including systems for primary care (Dodds & Leaver, 2003) and secondary care (Furukawa et al, 2003; Smith, 2003), were identified there was little research relating to mental health
Summary
A Medline literature search (1966 to September 2004) using the search terms MENTAL HEALTH, PSYCHIATRY, MEDICATION ERROR REPORTING and MEDICATION ERROR was conducted. The East Kent NHS and Social Care Partnership Trust introduced a medication error reporting system, entitled ‘Safemed’, based on a system developed by a community services pharmacist (Dodds & Leaver, 2003). It was designed as a ‘no blame’ system to encourage reporting and obtain reliable baseline data, with links to the National Patient Safety Agency and clinical governance mechanisms within the trust via the Drugs and Therapeutics Committee. Additional details to be listed on the form included any injury, action taken, contributory factors and suggestions for preventing a repeat incident
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