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News: Letters on prescribing errors

29 January 2010

A selection of your repsonses to the prescribing errors article in the previous issue.

The article gave a balanced view and recognised the multi-factorial causation of errors. Your recommendations reflected the need to address up-stream factors such as improved training, as well as wider determinants, such as the work environment.

However, your recommendations missed one important down-stream aspect: how mistakes are dealt with should they occur. No matter how well doctors are trained and how well wards are staffed, prescribing errors and ‘near-miss’ events are bound to occur. In this situation, a supportive response is required in order for those involved, as well as others, to learn from the experience. The prescribing errors I witnessed during my foundation training were never openly or explicitly discussed and, as a result, opportunities for experiential and eye-opening learning experiences were missed.  

Dr Gracia Fellmeth

 

I read the headline in the November/ December issue of GMCtoday, ‘GMC research shows how errors in prescribing can be avoided’ and turned eagerly to page eight to learn how. What I found was a piece of descriptive research flagging up areas where changes could be made with probable good effect. I agree there is enough there to justify further research but in the absence of some kind of control group in a proper trial, it is premature to conclude that we know how to reduce prescribing errors, let alone prevent them entirely.

Declan Fox

 

I found the juxtaposition of your article ‘Mistakes Happen’ with your own typo mistake in the following article title ‘...Office of the Health Professions Adjudicator (OPHA)’ (sic), rather illuminating. Your article stressed systems failure in prescribing. Your typo was a systems failure, in that spell checkers cannot accommodate all the millions of acronyms we now use, and are thus often disabled. I am sure we can all learn from this example.

Anthony D G Roberts