Ethical emergencies

935

SUMMARY OF DATA FROM SERVICES REVIEW DOCUMENT’ I

I

...I

-I

We believe that research in the care of desperately ill people is important and that society would not wish it to be obstructed. Major advances are being made in intensive care, especially in septic shock, and these have the potential to save many lives. It is better that new interventions should be studied systematically rather than on an ad hoc basis, as will inevitably happen if LRECs place insuperable difficulties in the way of researchers. Child Development Centre, St George’s Hospital, London SW17 0QT, UK

DAVID HALL

1. Petros

A, Bennett D, Vallance P. Effect of nitric oxide synthase inhibitors hypotension in patients with septic shock. Lancet 1991; 338: 1557-58.

*New appointment with shared responsibilities totally funded from Guy’s budget

at

Guy’s

and Lewisham,

AZT: zidovudine

although

SIR,-Medication

errors

or

on

azathioprine?

sometimes involve

drug

names

that

number of tests undertaken by each laboratory increased by an average of 10% per year. Unlike other teaching hospitals, the Guy’s clinical department is not supported by a large academic department, so the financial situation is comparable with Lewisham. Lewisham has adopted the currently popular structure of a small number of biochemists working with a large number of medical laboratory scientific officers (MLSOs), medical laboratory assistants (MLAs), and clerical staff (ratio 1/4-5), whereas Guy’s has maintained a larger proportion of biochemists (1/14). The table shows details of the staff structure, workload, and productivity of the two laboratories in 1990/1991. This clearly shows that the Guy’s site achieves the greater productivity. A wider range of tests including the more complex analyses needing substantially greater staff time are provided at Guy’s, suggesting even greater efficiency at that site. One possible reason for this large difference is the hidden cost of constant training and supervision of MLAs and low-paid trainee staff who have little motivation, often have poor sickness records, and tend to move on to alternative employment. Biochemists are highly trained scientists with a full understanding of the tests they carry out, ability to adapt quickly to new technology, and a far greater commitment to their work than trainees. They also, with medical staff, share the responsibility of providing advice out of hours. It may prove costly to switch from highly trained scientists to staff with limited skills and motivation when robotics technology may soon replace, not the highly educated staff, but the "button

sound alike or are spelled similarly.l,2 Two cases where azathioprine was ordered in place of zidovudine illustrate the serious risk in using abbreviations when communicating prescriptions. The two patients were HIV infected and had CD4 counts below 500/µl. One was a 27-year-old inpatient in the psychiatry service and the other was a 33-year-old woman being cared for on an obstetrics and gynaecology ward. The infectious diseases service had recommended antiretroviral therapy with "AZT" (for azidothymidine) and the prescribing physicians tried to locate AZT in the hospital’s computerised information system. However, in our system this drug can only be ordered by its generic name (zidovudine) or brand name (Retrovir). When looking under "A" section they could not find AZT and chose azathioprine by mistake. The orders for azathioprine were filled by the pharmacy but fortunately the errors were discovered in time-by the attending infectious diseases physician and by a doctor of pharmacy student. A similar incident3 demonstrates how easily error can occur when unofficial names of drugs are used. It has been suggested that the abbreviation AZT be abandoned in favour of ZDV, which more accurately reflects the generic name. However, it would appear wise to avoid abbreviations altogether. Had the prescribing errors reported here not been picked up in time the consequences for the patients (and the health care professionals) might have been disastrous.

pushers".

Philadephia College of Pharmacy and Science and Hahnemann University, Philadephia

S. BIRD M. J. MICHELIN P. A. TOSELAND J. TOWNSEND P. W. TUTT

Clinical Biochemistry Department, 5th Floor Guy’s Tower,

Guy’s Hospital, London SE1 9RT, UK

Philadelphia College

M. THERESA AMBROSINI

of Pharmacy and Science

Department

HILARY D. MANDLER

of Medicine,

Hahnemann

University, Philadelphia, Pennsylvania 19102, USA

CRAIG A. WOOD

J, Azzugnuni M, Di Romana S, Vanhaeverbeek M. Fatal confusion between Losec and Lasix. Lancet 1991; 337: 1286. 2. Kurth MC, Langston JW, Tetrud JW. "Stelazine" versus "Selegiline": a hazard in prescription writing. N Engl J Med 1990; 323: 1776. 3. Cohen MR. AZT: a dangerous abbreviation. Hosp Pharm 1988; 23: 691. 1. Faber

1. Coker N. Clinical services review: Trust. February, 1992.

Ethical

pathology services. London: Guy’s and Lewisham

emergencies

SIR,-Your correspondents (March 14, p 682) indicate some justifiable concern about the ethics of research on patients in intensive care, who are not able to give consent for such studies. As chairman of the Wandsworth Health Authority local research ethics committee (LREC) that approved the study reported by Petros and colleagues,l I would describe the view adopted by our committee members on this difficult issue. We do not believe that relatives should be asked to sign consent, since they have neither the moral nor the legal authority to do so. Instead, they are told about the project and given the opportunity to object on behalf of the sick person. The explanation given to the relatives must be witnessed by a senior nurse or equivalent person who is not directly involved with the research. Moral responsibility for research projects in this situation is shared between the investigators and the LREC, and the members must satisfy themselves that the project is of sufficient importance to justify an additional intervention in the care of a very sick patient.

Language tests for EC doctors graduates from developing adequately qualified practise medicine in the UK they are required to take the professional and linguistic assessment board (PLAB) test before they are allowed to register with the General Medical Council (GMC). The need for the English language component of the test for overseas graduates is indisputable, even though graduates from most countries-for example, those from the Indian subcontinent--are taught in English. Medical graduates from European Community (EC) countries SiR,—To

countries

are

assess

whether medical

are

exempt from such

to

assessment

and

are

entitled

to

GMC

registration because they qualified in the EC. An increasing number of EC graduates are being appointed to junior hospital posts in the UK. I was recently a locum medical registrar in a Scottish district general hospital. All five junior house officers were EC graduates (4 from Germany and 1 from Spain). Nursing and senior medical staff,