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To Err is Human, to learn Professional

“To Err is Human, to forgive divine” – While healthcare professionals may not necessarily seek forgiveness for error, they should seek one thing above all; to learn.

Last week in Dublin’s Royal College of Surgeons, Mena Eskander delivered a lecture introducing the topic of medication errors to the school’s second year undergraduate pharmacy students. Medication error is not an abstract topic,  nor is it solely the responsibility or concern of the dispensing pharmacist. Setting the scene first with an account of a fatal error associated with an OTC product, it was clear that one could be involved with medication errors even at the earliest stages of their career. In his lecture, Mena discussed the importance and benefits of using ICT to facilitate error reporting and shared learning across the sector to protect our patients.

Pharmapod has fast become the industry standard in the pharmacy sector for incident management for a variety of reasons. A major barrier to reporting with traditional systems is that they offer little-to-no benefit for the reporter. Pharmapod serves a real purpose for clinicians and helps them to fulfill specific tasks. They can do analysis, performance reporting, demonstration of corporate governance for inspections and effective management of customer complaints and compliments. As an added benefit, Pharmapod empowers dissemination of learning on a national level which will drive standards and ensure the quality in the Irish Healthcare system.

Much needed and welcome changes for the better are taking place in Irish Healthcare. A national patient safety office has been established and very recently, the Health Information and Quality Authority (HIQA) published a number of recommendations made to the Minister of Health. The recommendations highlighted the need for improving patient safety surveillance in Ireland. HIQA stated that services must share and act on information regarding patient safety incidents, and learn lessons to prevent similar incidents from reoccurring. To achieve this, HIQA propose a new model to coordinate patient safety intelligence in Ireland, part of which is the roll out of a national incident management system.

The recommendations underline the importance of establishing a single agency to oversee the governance and coordination of sharing learning between the numerous stakeholders who collect patient safety data. They also report the need for ICT infrastructure supported by effective governance to ensure lessons from patient safety incidents are shared locally and nationally which Pharmapod facilitates in a growing number of pharmacies in Ireland.


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