Aims and method: A new medication error reporting scheme ('Safemed') was introduced within the East Kent NHS and Social Care Partnership Trust. All medication incidents reported using this system in the first year were analysed by the Chief Pharmacist. Results: Over a 12-month period a total of 66 incidents were reported through Safemed, compared with 55 incidents under the previous system. The low level of reporting made detailed statistical analysis and drawing meaningful conclusions problematic. There was a large variability in reporting between similar sites. Clinical implications: The low level of reporting was associated with cultural factors, in particular the failure to fully implement a 'no blame' culture. Until such a culture is established, reporting will remain variable and a systems approach to preventing medication errors will not be adopted, leading to significant clinical risk.
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