The 6 year review of voluntary medication incident reporting by Cousins et?al. [1] is very interesting, and I agree wholeheartedly with its conclusions that the new National Health Service (NHS) must continue to interrogate the National Reporting and Learning System (NRLS) to mandate NHS organizations to make changes to reduce harms from, in particular, high-risk medication/practices. It is, however, impractical to expect health professionals voluntarily to report all medication incidents, because prescribing errors alone have been shown to occur in 8.9% of all medication orders written in UK hospitals [2]. This equates to approximately 40?000/year, of which 700 are potentially fatal, for an average 900-bedded hospital. The sheer ‘size’ of the medication error problem thus adds to the already accepted barriers to the reporting of any adverse events by health professionals [3], namely knowledge (what and when to report), outcomes (perceived lack of feedback and positive change), effort (simplicity of reporting form) and fears (personal).
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