I recently attended a seminar on the management of errors in medicines administration and got into an interesting debate with a fellow professional about how such errors are managed. Neither of us disagreed with the premise that a full investigation to establish the root cause of the incident was needed. Very few errors are entirely the fault of the individuals involved, as more often than not the systems around the process are faulty. We both concurred that there was also the chance that we had not provided enough training or support and therefore the person involved should not be held fully responsible.
On one issue, however, we did differ. The issue was about the way managers decided on the appropriate response to an error where a staff member was found to have been at fault. My colleague strongly believed that the level of response (from an informal counselling to all out disciplinary action) should be guided by the potential outcome of the error to the service user. For example, a member of the team had omitted to administer a prescribed skin lotion for eczema. My colleague felt that this was a lesser ‘crime’ than if the omitted medicine had been say, an anti-convulsant. He based his decision on how serious the consequence of the action or omission might be.
My stance was different. I contested that, no matter what the medication, no matter what the potential outcome, the fact remained that a staff member had failed to perfom a task that was required of them, i.e. to administer a medicine according to prescription. The omission was an error, and if our investigation found there were no systems issues or training shortfall, then the person had wilfully failed to carry out an instruction, then it did not matter what it was they had failed to administer.
My colleague argued that a proportionate response was fairer. I responded that if we did not recognise that following procedure was a requirement and permitted breaches where the outcome was not serious, we were in danger of creating a sloppy and reckless culture among staff. The message to staff should be clear around following instructions. In social care, the only safeguard for managers and indeed for organisations, is the knowledge that staff are acting in accordance with clear procedures. It is an assurance for service users, our staff and our services that care practice remains safe.
