Body to safeguard patients urged

Health seminar: A National Patient Safety Agency should be set up in the Republic, the Irish Pharmaceutical Union's annual healthcare seminar in Dublin heard yesterday.

Such an agency would collect and analyse incidents in which patients were given incorrect drugs or incorrect dosages of drugs.

This information would then be fed back into practices to prevent future mistakes.

Delegates heard of how the National Patient Safety Agency in Britain has led to increased reporting of the dispensing of incorrect medicines, dosage errors and near-misses.

This information is then fed into a national reporting system which is analysed and reported back to healthcare professionals to prevent further errors.

Speaking about patient safety lessons learned from the Harold Shipman case, Mandie Lavin, director of fitness to practise and legal affairs, Royal Pharmaceutical Society in Britain, said: "The regulatory changes that have been made in Britain don't mean that a Shipman case wouldn't happen again but such a case would be identified earlier."

The English GP killed up to 260 patients over a 23-year period in the Greater Manchester and West Yorkshire areas before being jailed and taking his own life.

"There is currently no national mechanism to collect data on safety information about medicines used in hospitals and in the community in Ireland," said Veronica Tracey, president of the Hospitals Pharmacists Association of Ireland.

However, Ms Tracey explained how hospitals' pharmacists do look at medication errors and how they can be proactive about drug safety through a medication safety special interest group.

Joanne Hillier, patient safety manager of the National Patient Safety Agency in Britain, stressed that a key feature to that system is anonymity.

"When incidents occur, we want to know the why and the how, not the who."

Some delegates suggested that for such a system to work here, there would also have to be a no-blame culture rather than the current litigious culture.

The most common errors reported were wrong/unclear dosage or strength of medication and omitted medicine or omitted ingredients in a medication.

The UK reporting system has also led to drug companies changing the design of packaging to differentiate medicines and adding crucial information to the outside of the packaging, such as this medicine contains penicillin.

The Irish Pharmaceutical Union also called for a broad focus to the forthcoming Pharmacy Bills due to be published shortly.

Dr Karl Hilton, president of the Irish Pharmaceutical Union, said: "It is extremely worrying that there is currently no legislation in force for pharmacists and pharmacy owners."

According to Dr Hilton, Ireland has the most liberal pharmacy market in Europe and anyone can open a pharmacy.

Dr Ambrose McLoughlin, registrar and secretary of the Irish Pharmaceutical Society, added: "The pharmacy legislation must be robust enough to ensure that patients and the public are not put at avoidable risk by their practitioner or the nature of the premises in which the pharmacy operates."

He added that the absence of pharmacists from those writing legislation was a deficit.

"You can't spend 12 per cent of the health funding on medicines and not have a pharmacist at the centre of healthcare policymaking," he said.