You cannot work for 20 years plus in a people-based profession such as ours without things going wrong occasionally. It happens. It can be admin, the prescription copied down incorrectly, a mistake transcribing negative and positive lens powers, a wrong patient record and so on. Sometimes, despite all safeguards, this causes someone’s spectacles to be made up incorrectly. This could lead to poor vision, even headaches or binocular vision problems.
In my career, I have heard of a minus lens being dispensed in place of a positive prescription, a 3.50 DC cylinder being glazed 90 degrees off, a 50 per cent tint being dispensed as a pair of night driving specs and PPLs being positioned 6mm below horizontal centre line rather than 6mm above. All of this is poor practise – but equally we are human, and we are fallible.
How you handle fallibility is much more important than your human failing. We must be candid, we must put our hands up sooner rather than later, declare there is a problem, what that problem is, and immediately talk to the people involved and agree a solution. Adverse incidents need to be documented, preferably signed by two people, and copies of the incident report kept with the patient record, and in a separate adverse incident log. If the error involves an NHS GOS transaction then it should be reported in the annual complaints report that contractors should complete every year.
Are you aware of the National Reporting and Learning System? Look it up: it isn’t about catching anyone out, it is all about identifying training needs for ourselves and how to implement them. Visit www.report.nrls.nhs.uk for more information.
Don’t forget: act quickly to resolve the concern, admit fault if you are at fault, and keep good documents and records. Do not try to cover anything up or deny culpability. Most of all, review your processes so the risk of future errors is reduced.
Most people are human enough to understand that accidents and mistakes happen; it’s how you handle them that’s crucial.