It is crucial to foster and support a no-blame culture with
regard to identifying adverse drug reactions (ADR) and reporting
them. This is to ensure that individuals can give an honest
account of why an ADR occurred.
An ADR may occur as a result of a hurried consultation or be due to
inadequate information being recorded in the patient's notes. Ensuring
that all the information regarding a consultation, such as the quality
of the patient's notes and the length of consultation, is documented
may assist in preventing other ADRs.
Recording so-called near misses is also important, to prevent future
such occurrences the next time it may not be near miss and could
lead to a patient suffering an ADR. Again, documentation is important
to help identify whether a system may need to be put in place or a current
one improved to ensure a near miss does not occur in a similar situation.
An ADR may be reported via the Yellow Card scheme, if appropriate,
and/or may be reported in your area of practice.
Make notes on any systems
that you are aware of for reporting ADRs or near misses within your
If you are unaware of any such systems, investigate whether
there is one in place and, if not, why not? Could it be that
people are afraid of being honest? How would you feel about
reporting that you had made an error that resulted in an ADR?
Maybe this would be a good time to suggest implementing such
a system, or even write a proposal for one yourself.
Further information about the Yellow Card scheme is available
British National Formulary (BNF)
Go to section entitled Guidance on Prescribing and read subsection 'Adverse Reactions to Drugs'.
- Consider and write down whom you would need to inform of a
- Consider and write down where you would need
to document this incident (such in a patient's
notes, the Yellow Card scheme and so on)
- What other actions would
you need to take?
- Ensure you are aware of what to report with
regards to 'black triangle' drugs and the
difference between a serious and a severe
- Consider issues regarding, adverse reactions
in children and older people, delayed drug
effects, congenital abnormalities and herbal
Link to 'Contraindications
to immunisation' in Unit 3. Prescribing
and the Wider Healthcare Context.
Griffith, R. (2006) Adverse drug reactions and non-compliance with prescribed medication. Nurse Prescribing, 4 (2) 69-72.
Cossey, M. (2004) Applied pharmacology in Courtenay,
M. and Griffiths, M. Independent and Supplementary Prescribing:
An Essential Guide. London: Greenwich Medical Media. Chapter
7. Adverse Drug Reactions, 93-95.
Wong, I. (1999) Pharmacovigilance resources in
the United Kingdom. Pharmaceutical Journal
263: 7059, 285-288.