Medication errors

Medication errors

In 2000 an expert group chaired by the Chief Medical Officer published a report entitled An Organisation with a Memory, which summarised the scale and nature of serious failures in NHS healthcare and made recommendations on how lessons should be learnt from errors and near-misses and how to minimise the likelihood of repeating these errors in the future. This was followed in 2001 by Building a Safer NHS for Patients, which set the NHS targets for implementing the recommendations from An Organisation with a Memory. It established a national agency, the National Patient Safety Agency (NPSA), which has the remit of collecting and analysing information on adverse events in the NHS, assimilating other safety-related information, learning lessons and ensuring they are fed back into practice, producing solu-tions to prevent harm where risks are identified, specifying national goals and establishing mechanisms to track progress. The NPSA continues to produce and issue patient safety alerts, rapid response reports and guidance on design for patient safety and is discussed further in Chapter 12.

QA pharmacists have a key contribution to make towards achieving these targets, in assisting with the reporting, analysis and feeding back of informa-tion regarding medication errors, and in ensuring that appropriate systems of QA, QC and audit are in place throughout all areas of pharmacy practice.