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tips on . . . Safe prescribing With a fresh cohort of house officers gracing our hospital wards, here’s a quick reminder of the basic principles of prescribing safely.
Before prescribing x Assess the patient thoroughly, making sure the drug is appropriate and not contraindicated x Always ask if the patient is allergic to any drugs; if this is not already documented, write it down x Take into consideration any medication the patient is already taking, checking there are no interactions x Consider alternative therapies and discuss these with the patient.
When prescribing x Check that you are prescribing the correct agent to the correct patient x Use generic drug names rather than brand names. Don’t use abbreviations x Check the dose, frequency, and route of administration are correct and appropriate for the patient. Include a start date and a review date x Avoid unnecessary zeros (for example, 1.0 mg), which may be misread, and make sure the units you use are correct x If in doubt, refer to the BNF x Make sure your prescription is legible and easy to read, including your signature and bleep number x Explain what you are prescribing to the patient and why; describing how and when to take medication increases compliance and reduces confusion.
After prescribing x Watch out for any unprecedented reactions x Make sure you monitor levels or organise follow-up tests if indicated x Review the indications for the drug regularly. This prevents patients from taking medications they don’t need to take x Upon discharge, make sure you document any alterations made in a patient’s medication and pass them on to their GP. j Shreelata Datta senior house officer in obstetrics Queen Charlotte’s and Chelsea Hospital, London
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these are avoidable errors,” he claims. Moreover, “many of these errors occur because either simple basics such as a full history and examination are not performed, or the limitations of investigations and treatments are not fully appreciated or communicated adequately to the patient. The best form of defensive medicine is good medicine!” he concludes.
Why are errors not being reported? “It may be the case that an error is never realised, or not realised until later. It seems, though, that the culture is not to speak out. Indeed, to do so may well harm your career prospects,” says Brahams. “In my experience, there is usually more than one lost opportunity to admit to an error, and doctors even when the evidence is stacked against them will still refuse to admit liability”—fear perhaps of failure, of being scapegoated, or simply professional arrogance? Additionally, “there’s a ‘blame culture’ in medicine,” says Dunn. “Doctors don’t want to take on personal responsibility because they know ‘where there’s blame, there’s a claim!’ ”
electronic system similar to that employed by the airline industry, where data could be inputted, rapidly analysed and constructively fed back would improve patient care. More than 80%, however, did not trust the Department of Health or their NHS trust to run such a system, with concerns raised regarding anonymity, confidentiality, and the responsible use of the data obtained.
Education In addition, “responsibility needs to be shifted away from the doctor, to the patient,” suggested a member of the audience. “We also need to educate and be honest with patients,” says Dunn. “I had a patient who I had fully consented for a total knee replacement who subsequently self-discharged and had his operation performed somewhere which apparently had ‘no complications’ associated with the same procedure!”
Conclusion When can a mistake save a life?
Tackling the culture of under-reporting in the NHS
Sadly, it seems a culture of blame and fear of adversarial complaints continues to pervade medical practice even today. It appears that doctors are willing, at least under the cover of anonymity, to confront clinical error, but although anonymity is a requisite for engaging and educating doctors, it is a concept that doesn’t sit well with accountability and transparency, and is likely to lay the profession open to further accusations of fostering paternalism. Change is desperately required, not least for the safety of our patients, but unless the climate is also right, it is likely to prove difficult to implement. j
Contrary to public perception, doctors themselves are crying out for a change in the system. 97% of doctors surveyed by Doctors.net.uk believed that an
Kaji Sritharan vascular research fellow
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“A doctor who fails to learn from his mistake is doomed to repeat it,” he continues. “We need to change a negative event into a positive event, link error with a process of education, not initiate witch-hunts,” urges Ringrose. “Educational resources need to target areas where errors are being made. We also need to look at the systems in place and examine the points at which they fail—employ what’s known in industry as root-cause analysis.”
tips on . . . Communicating with colleagues Cater for your audience—When imparting information to a group of colleagues, try to find out beforehand what they want to know. Do they want information in the form of regular emails or do they want to be told during a talk or meeting? Get people on your side—If you are leading a particular initiative, it is a good idea to get a few colleagues on your side. This helps to spread the word. It also helps if the small group of followers are from different layers in the organisational structure Know where you are in the organisation—At the end of the day we are all cogs in a much bigger wheel. Knowing where you are in the organisational structure gives you a better idea of how you can influence change through information Integrate your personal strategies—It is always easier to get your message across if what you are offering already fits the organisational strategy. By being aware of the bigger picture you will be in a better position to integrate your own ideas Keep it basic—If possible, keep the message or information as simple as possible because this will increase overall understanding. Most communications should contain only two or three core messages Don’t forget to talk to people—Nowadays, information dissemination can come in a variety of different forms such as emails, newsletters, noticeboards, and memos. Face to face interaction is still one of the best ways to get your message across Avoid obvious pitfalls —It goes without saying that when you are communicating with individuals you should avoid being patronising or too positive Follow up—To judge the success of what you have done you must evaluate and measure outcomes—otherwise you will have little idea whether what you said actually worked or had influence. There are many ways of evaluating outcomes, including cost savings and increased productivity. Identifying what you hope to achieve will help when setting the initial criteria j Mark Griffiths Psychology Division, Nottingham Trent University
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10 SEPTEMBER 2005
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