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Tuesday, 12 February, 2002, 10:37 GMT
'NHS must learn from its mistakes'
Operation
NHS chiefs are determined to learn from mistakes
England's Chief Medical Officer, Professor Sir Liam Donaldson, has said that the NHS must improve its own safety culture in order to reduce the number of medical errors.

Speaking on tonight's File on 4 programme, Sir Liam says it is important that mistakes are fully acknowledged and that lessons are implemented across the health service.


e have to have a way of ensuring that the bad experience of one patient is used to prevent harm coming to the next patient

Professor Sir Liam Donaldson
He says: "Human error is inevitable but the failure to learn as a system, as a healthcare system, is the bit which we should be accountable for.

"It's at the system level where we have to have a way of ensuring that the bad experience of one patient is used to prevent harm coming to the next patient to come along with a similar problem."

Sir Liam was interviewed as part of the programme's investigation into the rising number of errors in the way medicines are prescribed and administered.

Unnecessary deaths

A recent study by the Audit Commission claimed there are around 1200 deaths every year from adverse drug events - a five-fold increase over the past ten years.

Some of the deaths are due to patients simply being given the wrong drugs while in other cases they are given the right medicines but at the wrong dose or in the wrong manner.

Professor Sir Liam Donaldson
Professor Sir Liam Donaldson is trying to raise standards
In October, Teresa Innes went into Bradford Royal Infirmary, to have an ulcer treated on her leg.

She is allergic to penicillin, and her notes and hospital bracelet said so. Nonetheless, she was given the antibiotic and is now on a life support machine.

In another, widely publicised accident last year, 18 year old Wayne Jowett died after having a powerful chemotherapy drug injected into his spine rather than into his veins.

His mother Stella Brackenbury tells the programme of her horror that such a mistake could occur.

She says: "A consultant from the adult intensive care took us into a room and said, that he was expecting our son to die.

"He was conscious for the first two and a half weeks and then he slipped into a coma as his system started to pack up.

"They wanted us to tell him he was going to die, and I couldn't tell him because we wanted him to fight on but I think he knew."

Since 1975 there have been at least 14 incidents of chemotherapy drugs being injected into the spine when they should have been given intravenously and the government has set a target of eliminating these errors altogether.

Packaging problems

Wayne Jowett
Wayne Jowett died after a cancer drug mix-up
But in another category of mistakes, the government has been criticised for not doing enough to press drug manufacturers to change their packaging in order to make drugs more distinctive.

According to pharmacist, Simon Whitaker, patients are being put in danger through confusion.

He says: "We are faced with a situation now where we have lots of packs of tablets and capsules which look very similar, although the drugs as they contain are vastly different.

"There is clearly a concern that patients taking an incorrect medicine as a consequence of somebody mistaking one pack for another could have potentially serious consequences.

"There was one incident that was reported in which a patient died as a result of picking the wrong medicine."

The Committee on Safety of Medicines has set up a working party which is consulting drugs manufacturers on the issue and Sir Liam says he is aware of problems with packaging.

However, he claims government action is limited by the global nature of the pharmaceutical industry and the need for European regulation.

He says: "We have leverage, but we are not omnipotent.

"There are many other countries spending a lot of money on drugs as well, and we have to be aware of the fact that if we are to make the biggest impact we can do it better if we bring other countries in along with us.

"But if we felt there was an area where we could take direct action ourselves, then we would certainly be prepared to do so."

File on 4 is broadcast tonight at 8pm and repeated on Sunday at 5pm on BBC Radio 4.

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