Upfront: Medical mistakes

The underlying philosophy of “to err is human” is that everyone is capable of making an error. It is not a human failing but human nature. Academic qualifications, experience, judgement and knowledge do not exempt a person from being human. We can, however, take steps to minimise the impact that errors may have, and the frequency with which they occur.

Perhaps one of the most important aspects of minimising medical errors is questioning things that do not seem right. Practitioners should feel encouraged to question a colleague if an error is suspected, rather than feeling embarrassed or awkward in the face of authority or reputation. Questions from patients and their families about medical care, prescribing or dispensing should be welcomed rather than dismissed or discouraged.

What is medical error?

Defining an error is a challenge as every event will be perceived and interpreted differently by each person involved. Often it is easy to disown an error or shift responsibility - “that was not my fault, it was a problem with the system” or “if my information system was up to date, I would not have prescribed the wrong medicine”. Errors usually have multiple causes with several people or systems involved in a cascading chain of events. The responsibility for error prevention is collective and collaborative rather than resting on the shoulders of an individual.

Medication errors

Medication errors are the most common type of medical error that occur in primary care. A medication error can be defined as; “failure of the treatment process that leads to, or has the potential to, harm the patient”.²

Medication errors may occur during the following processes:²

• Choosing the medicine and dose - prescribing faults (irrational, inappropriate, ineffective prescribing, under or over-prescribing)
• Writing the prescription - prescription errors, illegibility
• Dispensing the medicine - wrong drug, formulation or label
• Manufacture or preparation of the medicine - wrong strength, contaminants
• Administering or taking the medicine - wrong dose, drug, route, frequency or duration
• Monitoring - failure to alter a treatment when indicated, erroneous alteration

Methods to minimise error

Most healthcare professionals are likely to have had some experience of medical errors, including near misses and errors that occur but are undetected. So what can be done in primary care to reduce medication errors and improve patient safety?

1. Review medication errors with practice colleagues and peers - discus what went wrong (including near misses) and consider factors that could be put in place to prevent future events.
2. Introduce a culture of openness, no blame and collective responsibility - many error incidents are not single acts but result from a chain of events. GPs, pharmacists, practice nurses and other primary care practitioners all have a role and responsibility in selecting, delivering, receiving and administering medicines correctly.
3. Involve patients in their own safety - collective responsibility for error prevention extends to patients as well. Patients and their families should be informed about the medicines they are receiving and encouraged to act on their suspicions if they feel something is not right.
4. Be extra vigilant with high risk medicines and situations - some factors increase the risk of an error occurring. Patients who have been recently discharged from hospital are especially vulnerable to error due to factors such as confusion over medicine changes, poor information transfer and lack of follow-up. High-risk medicines such as warfarin and opioids, polypharmacy and prescribing to very old or very young people, may also warrant closer attention to prevent errors.
5. Report errors and patient safety incidents - decide individually or as a practice what method should be used.