Jeffrey Aronson: When I use a word . . . Errors

jeffrey_aronsonThe village of Erice sits above the town of Trapani on top of a mountain about 750 metres above sea level in the north-west corner of Sicily (picture below). Its original name was Ἐρυξ, after the Sicilian king of that name, a son of Aphrodite and either Boutes, an Argonaut, or Poseidon, the god of the sea. Eryx ruled over the Elymoi in western Sicily. When Herakles visited the island, Eryx challenged him to a wrestling match, staking his land against Herakles’s cattle. Herakles killed him and Eryx was buried on the mountain where he had erected a temple to his supposed mother, Aphrodite.

Erice’s Castelo di Venere commemorating Aphrodite

The village still bears his name, although the mountain is now called Monte San Giuliano. The Greeks then claimed the land—which had originally been established by the Phoenicians, evidence of whom can be seen in the nearby island of Mozia (Μοτύα)—but their claim was contested by the Carthaginians, who occupied the land in the 3rd century. Daedalus is said to have built the wall that encloses the area at the top of the mountain, creating a fortress. Later Erice became a religious settlement, its monasteries named after such saints as Rocco, Francesco, and Domenico.

The Via Gian Filippo Guarnotti—the Ettore Majorana Foundation is on the left just before the arch

Then in 1961 a group of physicists, led by Antonino Zichichi, established the Ettore Majorana Foundation and Centre for Scientific Culture in Erice, naming it after the brilliant Italian physicist Ettore Majorana, who was born in Sicily in 1906 and disappeared mysteriously in 1938. The foundation hosts conferences in 126 physical and biological sciences; my Veronese colleague Giampaolo Velo leads the pharmacology school.

This year we organised a three day Erice conference on medication errors, following the conference that we held there in 2008. In 18 lectures given by 16 faculty members, our 30 students learned about topics ranging from definition, classification, contributory factors, detection, and prevention, to regulatory and legal aspects, pharmacovigilance activities, and the roles of computers, barcodes, and control theory.

When a systematic review in 2008 showed that 4–82% of prescriptions written by junior doctors contained medication errors, this wide range was attributed in part to variations in the definitions used in different studies. A uniform definition was needed, and now the definition that Robin Ferner and I proposed in 2000 has been adopted by the European Medicines Agency, with a single word added.

Previous definitions had suffered from various defects, including circularity (for example, defining a medication error as “any error occurring in the medication process”) and reference to factors that are irrelevant to the identification of medication errors, such as preventability, the individuals responsible, and standards of care or recommended practices or policies. The folly of referring to these as touchstones is underlined by Ambrose Bierce’s definition, in The Devil’s Dictionary, of an error as “an action that is contrary to my beliefs and actions.”

The Indo-European root ERS meant to be in motion, giving the Latin word errare to wander and hence to err. A metathetical version, RĒS, gave the English word race via Scandinavian derivatives, and a zero grade version, RS, gave the Indian word rishi, a holy poet or wandering minstrel, describing the sages who were thought to have composed the Vedas. These roots are also related to WERS, which meant to confuse or mix up, giving wurst, which is meat mixed up, and the adopted name of a Eurovision winner whose sex seems clear but whose gender is confusing, a crucial distinction that is often misunderstood.

“Error” is defined in the Oxford English Dictionary as “something incorrectly done through ignorance or inadvertence; a mistake, e.g. in calculation, judgement, speech, writing, action, etc”. However, the acknowledged expert in the field of errors and the psychological factors that underlie them, James Reason, has a different definition: “The failure of planned actions to achieve their desired ends without the intervention of some unforeseeable event.” Reason’s position derives from the observation that errors occur when plans are either wrong or are carried out incorrectly, despite being correct, that “something incorrectly done” implies a failure, and that errors do not always result in harm.

These definitions of error, largely ignored in previous definitions, laid the foundations for our definition of a medication error, which I shall discuss next week.

Jeffrey Aronson is a clinical pharmacologist, working in the Centre for Evidence Based Medicine in Oxford’s Nuffield Department of Primary Care Health Sciences. He is also president emeritus of the British Pharmacological Society.

Competing interests: None declared.