Reducing your risk: Reducing medication errors requires a non-punitive approach


To uncover drug errors, it's best to use a nonpunitive approach.

On a cloudy night in December 1974, a TWA airliner was approaching Dulles Airport in the suburbs of Washington, D.C. Misunderstanding a communication, the plane dropped below what was considered a safe altitude. TWA flight 514 struck a mountain top, killing all aboard.

From that lesson evolved a partnership between NASA and the FAA that led to the creation of the national Aviation Safety Reporting System (ASRS). Today, information such as might have saved the passengers aboard TWA 514 is shared throughout aviation. Reports of every accident and near-miss are reported and analyzed. ASRS has led to a quality system of continuous improvement, often described as the best in the world.

From the ASRS model we can develop a simple strategy:

According to a study at Auburn University, pharmacists make one mistake with each 65 prescriptions dispensed. In this country, it is estimated that more than three million potentially serious prescription errors walk out of community pharmacies each year.

I have talked to prosecutors and board members who have tried to explain to me that their actions regarding punishing pharmacists for making an error was to prevent future errors and injuries. They are wrong. They should not think their punitive actions will have a positive impact on safety. It will probably have the opposite effect. Other pharmacists will become reluctant to share information about a mistake they made. Lessons will be lost. The pharmacy equivalent of TWA 514 may not be prevented.

A pharmacy can institute a non-judgmental, non-punitive system for staff to share information and learn from the mistakes we all make. If your pharmacy does not have a quality system that can be used to tell you where, when, and what kind of mistakes are made in your system, you should consider instituting one.

One such system is available through your state pharmacy association. The program is inexpensive – no, actually, it is cheap. The Pharmacy Quality Commitment system is available through all state associations, thanks to the National Alliance of State Pharmacy Associations, a nonprofit organization dedicated to safety and pharmacy. When you put such a system in place, follow the guidelines set out by NASA and the ASRS reporting model. In particular, make sure reporting is non-punitive.

THE AUTHOR consults in the areas of pharmacy error reduction and risk management. He is an attorney, of counsel, with the Arizona law firm of Renaud Cook Drury Mesaros, PA. References for this article are available at

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