Inaugural Medication Safety

Now under the umbrella of the Committee for Specialty Practice (COSP) in Medication Safety, the aim of the Medication Safety series remains unaltered since 1997: to share stories about errors and near misses with the intention of preventing their recurrence throughout Australian hospitals. Michael Cohen and his USA colleagues created a similar journal column many years earlier with the same aim. With Michael’s encouragement, many of that column’s – now the Institute for Safe Medication Practice (ISMP) newsletter – stories have relevance to our practice in Australia and, blended with local reports, have been shared with our readers to locally predict both current and future opportunities for error. Use of this valuable strategy of storytelling has morphed into the modern proactive risk management technique of Failure Mode and Effects Analysis (FMEA): taking a hypothetical scenario and asking a clinical team ‘Could this happen here?’ This strategy can be used to change practice incrementally and communicate concerns to clinical teams, consequently enhancing the medication safety culture within an organisation. We now know that regular proactive risk management in this guise is not only a relatively enjoyable pharmacy staff meeting activity, it is also highly valued by hospital accreditation surveyors. A growing Australian database of local error reports is held securely and Australian hospital pharmacists are encouraged to contribute by submitting details of any error occurring or prevented at their site and share these in the spirit of future prevention through reporting, via email, to medsafety@shpa.org.au. The identity of the reporter will never be revealed and the editor has been known to elaborate the message creatively to de-identify its source without changing the key message. It is believed that through growing readership of this series, the local landscape of medication safety awareness continues to improve.