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Medication errors. Lessons for education and healthcare
  1. C E Brookes

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    R Naylor. (Pp 333; price not stated). Radcliffe Medical Press, 2002. ISBN 1-85775-956-7

    “Never judge a book by its cover!” This proverb has particular relevance to Professor Naylor’s book as “medication errors” discusses a wide range of challenging issues. In particular, as well as an account of drug errors and their aetiology, it also provides a relevant and detailed commentary on adverse event reporting, risk management, and, consequently, clinical governance.

    About one million patients a day in the UK visit their doctor or hospital interacting with 700 000 healthcare staff. Many of these patients receive medication and even with a low error rate of 0.0001%, this would still result in a hazard to around 255 000 patients a year. As such, drug errors are undoubtedly an important public health risk and the single commonest form of medical error.

    The book defines the extent of this global problem in all healthcare environments. Professor Naylor is both incisive and controversial in his analysis of the causes, risk factors, and cost of medical errors. The effect of high intensity workloads, especially in critical care settings is explored. He also details the introduction of the “NPSA” in the UK following the landmark reports “An organisation with a memory” and “Building a safer NHS for patients.” In addition, he challenges the “blame culture”, which is seen as a major barrier to the openness required if sentinel events are to be reported, lessons learned, and safety improved.

    Root cause analysis of cases of methotrexate toxicity and intra-thecal administration of vincristine and vinblastine provide the reader with insight into the aetiology of these catastrophic errors. Strategies to prevent repetition are also explored along with general measures to reduce the risk of adverse events.

    Professor Naylor also emphasises the pivotal part education and knowledge play in minimising drug errors. He questions whether the medical undergraduate course fails to provide graduates with the necessary skills to prescribe and administer medications safely. Controversially, he also challenges the efficacy of courses directed towards problem based learning particularly where this approach is combined with a reduction in the curriculum’s factual content.

    The implications this presents with respect to continued professional development are discussed. Furthermore, the continued dilution of generalist knowledge by the development of increased specialisation is highlighted as a factor in limiting professional competence in prescribing.

    Throughout the book, Professor Naylor’s commentary explores many entrenched principles. He consistently addresses difficult and challenging issues in a perceptive and thought provoking manner. As such, I would commend this book to any practitioner delivering medical care even if they based their reading on the succinct summaries provided at the start of every chapter. Certainly, a colleague of whatever discipline with an interest in risk management, would find it compulsive reading.

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