It’s riskier to keep your errors to yourself

Rima Verma, newly qualified locum pharmacist caused quite a stir in a small conference room somewhere in Birmingham as she raised the subject of barriers to reporting dispensing errors in community pharmacy.


No one likes being in the wrong. As pharmacists, it can sometimes seem like the errors need to be focused on and blown out of proportion. In the UK we have been brought up in a just system where mistakes do not go unpunished so it is no wonder that pharmacists are reluctant to report errors on a national level due to fear of prosecution or punishment, or blame being placed, among other themes highlighted by Miss Verma.

Miss Verma concluded that these barriers to reporting could be overcome through the creation of an open and fair ‘just culture’ as well as having a clear, easy to use and access procedure in place –saving time, complications and lack of knowledge of reporting systems– would help increase the quantity of error reporting.

It was surprising to hear how little dispensing or other incidents are reported on a national level. According to Miss Verma approximately only 270 out of a possible 276,000 errors are actually reported. David Cousins from the NPSA revealed that there are a potential 12 million errors a year that could be reported and, distributed among 12,000 pharmacies; there is a possible 3 errors a day that could be reported.

But what about prosecution?

“These are myths” says Mr Cousins, who gave an interesting explanation that no error that has ever been anonymously reported to the NPSA has ever resulted in prosecution. Often, prosecution is a result of family or carers complaining about the medication error about their loved one, not the pharmacist’s report.

Prosecution, maybe not, but Pharmacists can still lose their jobs, raised a representative of the Pharmacist’s Defence Association. He added that “breaching of an SOP” can be enough grounds for an employee to be dismissed, an unsolved issue of why a barrier to local reporting of errors might remain.

We all know that human error is inevitable and the sooner this is accepted the better. ‘Getting rid of the person doesn’t get rid of the problem’, another PDA representative added. Mr Cousins was keen to emphasise how much increased reporting would dramatically help to improve guidelines as well as safety in using specific drugs as he says; “It’s far riskier keeping your incidents to yourself”.


By Deborah Atkins


Last updated
The Pharmaceutical Journal, It’s riskier to keep your errors to yourself;Online:DOI:10.1211/PJ.2012.11106415

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