According to a news article on today’s BBC website, numerous mistakes are being made in a high number of drug treatments given to children in hospital. A study carried out by the University of London found some shocking stats on prescription errors.

So the Shadow Health Secretary Andrew Lansley says that the Conservatives would, ‘improve the data collection of errors in the NHS and incentivise year on year improvements in avoidable incidences’. Great! If the Conservative get in, let’s not report any more prescribing related issues and take the big cheque when they see the massive reduction in numbers.

Of course I am not being serious; the only way to reduce the numbers of incidents is to report, report, report, analyse what has been reported, find the root cause, and take action to reduce the risk that it might happen again - we all know this, it’s not rocket science.

If you look to other sectors that are seen to lead the way in safety, like Aviation, they operate in a manner that encourages their staff to report even seemingly innocuous issues, they take the view that their staff should tell them everything, and they will decide if it has further significance or not.

Radiotherapy is a good example of this same approach coming into effect in the NHS. The ‘Towards Safer Radiotherapy’ report recommends that all Radiotherapy incidents, regardless of their severity, should be reported to the NPSA, and through this, they should be able to improve National Learning and in turn provide a safer service.

The report from the University of London says that the Pharmacists found and corrected errors in 13% of almost 3,000 prescriptions, but a third were dosing errors. What would be interesting is where this stat came from. Did it come from the Trusts Clinical Incident Report system? Probably, in which case would the Trusts involved be 100% confident that that number matches exactly the number of errors that were actually found by the Pharmacists during this time?

You see the problem with error reporting is that it is time consuming, sometimes it’s a paper form filling activity that then needs to find it’s way into the right hands and not fall off a desk or get lost along the way, sometimes you need to find a computer, and even then, you need to have a Licence to use the Incident Reporting system - the obstacles soon start to mount up.

If I was a Pharmacist what would I consider the easiest way to report an error, and what tools would I have at my disposal to let me do this? Would I have a mobile phone that I can use on the ward and call in the issue, i.e. dictate it over the phone and have it raised without having to type/write up a report. Would I find it easier to fill out a form on my laptop there and then, and have it sync automatically with the Trust reporting system as soon as I come into range with a wireless network. As I tend to live in my Inbox, email would be my ideal scenario.

The reality is that the easier it can be made for the Pharmacist to report the error, or any near misses, then the better chance Trusts will have in reducing the number of errors that do result in harm.

If you work in Pharmacy I’d love to hear your thoughts on what your nirvana would be for reporting errors, what tools you have to hand when you do your rounds, or any other comments you have on the report.