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 det ermine reasons for mistakes and possible remedial measures. Ideas are drawn from industrial sources to describe a model of preventing mistak es at source, by making errors impossible. The ideas of Crosby and Shi ngo are discussed and a 'zero defects philosophy' is described and dev eloped. This paper attempts to determine if this quality model develop ed and used in industry can be transferred to the health service, and concludes that it needs adaptation and cautious application. Recommend ations are made for improved practices and improvements, both clinical and managerial. The author recommends a multidisciplinary review of a ll practices and systems to develop a radically different procedure wi th no drug errors as its aim. It is questioned whether this is possibl e in the present health service environment, as this would require sus tained management commitment to both the idea and the quality system. However, the author believes that some of the principles can be applie d as individual quality initiatives.