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In this edition we have a number of articles on both risks and managing risks. We should remind ourselves why minimising the risks of medicine use is so important. It is not to do with litigation, reputation of hospitals or the extra work and costs that misadventures cause. It is because at the end of everything we do is a patient, and it is our professional duty to ensure that they get better and we do not inadvertently cause them harm. Pharmacists, unlike doctors, do not take the Hippocratic oath, but one of its major tenets is “first do no harm”. This is a laudable aim and should need no oath to be central to all pharmacists’ practice.
Much of our work involves reducing the risks that are generated by other healthcare professionals. We review prescriptions, carry out drug histories, advise nurses on how best to give medicines, and prepare total parenteral nutrition, cytotoxics and intravenous admixtures to prevent others making mistakes in preparing complex regimens. We also counsel patients to ensure that they use their medicines effectively and safely, and we ensure that our labelling is clear, unambiguous and gives the correct instructions.
However, do we look at our processes to ensure that pharmaceutical activity does not introduce risks to patients? We quite proudly (and rightly so) point to the fact that dispensing error rates are very low. We are confident that our checking systems ensure that most errors are picked up before the medicine is issued to patients. Our hospital production units are subject to stringent outside scrutiny and in many countries are licensed by governmental authorities in the same way that industry is.
But do we examine the underlying risks and root causes of errors? Perhaps we have engineered many of these out by our attention to making systems safe. I think that we have done a lot, and we are well ahead of many of our colleagues in healthcare. Our experience is something that we can contribute across the hospital, not only in medicines management systems but in all risk management applications. On the other hand, we must not become complacent. We moved a couple of years ago to a patient pack system of dispensing. The literature suggests that this can introduce new risks due to similarity of packaging, labelling, etc. We also have had a small number of dispensing errors that we felt were due to these factors. I got some of our students to carry out a risk audit of our dispensary shelves and identify any risks that may occur. They found that 25% of our stock was associated with some form of risk, similarly named drugs close to each other on the shelf, similar packaging for adjacent drugs, multiple strengths with the same packaging and co-located, and so on. We are now looking at ways of reducing these risks, but the finding has had a salutary effect. As pharmacists we are very good at reducing risks from medicines, but there is still much that has to be done. I would challenge you to look at your pharmacy and see whether you have eliminated all the risks.
Chris Cairns, Consultant Editor