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A medication error reporting scheme: analysis of the first 12 months

East Kent NHS and Social Care Partnership Trust, Trust Headquarters, St Martin’s Hospital, Littlebourne Road, Canterbury, Kent CT11AZ, tel: 01227 812115; fax: 01227 812296; e-mail: ian.maidment{at}nhs.net

Angie Thorn, Prescribing Support Pharmacy Technician

East Kent NHS and Social Care Partnership Trust, Canterbury

AIMS AND METHOD

A 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.

RESULTS

Over 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 IMPLICATIONS

The 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.

This article has been cited by other articles:

				I. D Maidment, P. Lelliott, and C. Paton Medication errors in mental healthcare: a systematic review Qual. Saf. Health Care, December 1, 2006; 15(6): 409 - 413. [Abstract] [Full Text] [PDF]