CAN A ZERO DEFECTS PHILOSOPHY BE APPLIED TO DRUG ERRORS

The literature reveals that errors of drug administration are a widely distributed and common occurrence. The frequency of errors and their underlying causes are discussed, and the literature is surveyed to determine reasons for mistakes and possible remedial measures. Ideas are drawn from industrial sources to describe a model of preventing mistakes at source, by making errors impossible. The ideas of Crosby and Shingo are discussed and a 'zero defects philosophy' is described and developed. This paper attempts to determine if this quality model developed and used in industry can be transferred to the health service, and concludes that it needs adaptation and cautious application. Recommendations are made for improved practices and improvements, both clinical and managerial. The author recommends a multidisciplinary review of all practices and systems to develop a radically different procedure with no drug errors as its aim. It is questioned whether this is possible in the present health service environment, as this would require sustained management commitment to both the idea and the quality system. However, the author believes that some of the principles can be applied as individual quality initiatives.