Reporting of errors should be free of recrimination

BMJ 1995;311:1367 (18 November)

Letters

Reporting of errors should be free of recrimination

EDITOR,--We support R E Ferner's sentiments regarding errorsof prescribing.¹ There is a profound need for strategies thatmanage such errors by reviewing systems rather than by apportioningindividual blame. Hopefully, the recent papers in JAMA, citedby Ferner, will stimulate debate on drug errors and encouragethis process.

For several years we have campaigned for multidisciplinary medicationquality assurance groups to be established in NHS hospitals.²These groups should aim to create a non-threatening environmentin which all staff who prescribe, dispense, and give drugs feelable to report adverse incidents voluntarily, free from fearof recrimination. Reporting may be anonymous if this is thoughtappropriate, but in our experience staff are commendably forthrightin adding their name to completed records, which aids the identificationof individual training requirements. Completed reports are reviewedregularly by the quality assurance group and recommendationsare made to all staff as to how . . . [Full text of this article]