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Preventing medication errors and improving patient safety.

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The National Patient Safety Agency (NPSA) has recently launched its safe medication practice work programme for 2007-2008, which includes five patient safety alerts (NPSA, 2007a). It has also produced a report on improving the use of medicines in the NHS, which comprises an analysis of medication incidents and outlines the safe medication work programme (NPSA, 2007b).

In the UK, medication errors are a growing problem (Banning, 2006). The government is committed to reducing the number of serious errors in the use of prescribed drugs in the NHS by 40% (Smith, 2004), an aim first set out in An Organisation With a Memory (DH Expert Group, 2000). The chief pharmaceutical officer has stated that medication errors occur in all healthcare systems, adding that serious errors harm patients and expose health professionals to civil liability and sometimes criminal prosecution (Smith, 2004). The CPO also emphasised that such errors occur too frequently and are preventable.

Smith (2004) explained that although many side-effects or adverse reactions to medicines are predictable and accepted treatment risks that can be avoided or minimised by careful medicine prescribing and use, some adverse reactions are unpredictable and therefore unavoidable. This report, however, insists that errors - mistakes, slips or lapses made when medicines are prescribed, dispensed or used - are always avoidable.

Preventing medication errors is an even more important issue with the extension of nurse prescribing. From May 2006 qualified independent nurse prescribers were able to prescribe any licensed medicine for any medical condition within their competence, including some controlled drugs.

Data analysis

The NPSA report on improving the use of medicines in the NHS (NPSA, 2007b) describes key learning from analysis of almost 60,000 medication incidents reported by NHS staff to the agency’s National Reporting and Learning System (NRLS) between January 2005 and June 2006.

Medication incidents were the second most common type of incident reported to the NRLS, after patient accidents, during this period. However, for some patients (children) and in some settings (general practice) medication safety incidents were those that were most commonly reported. From January 2005 to June 2006 NHS staff reported 59,802 such incidents to the NRLS - representing 8.3% of all incidents reported. Just over 80% of these occurred in acute, general and community hospitals; only 4.9% occurred in primary-care settings.

The majority of reported medication incidents (83.1%) resulted in no harm to patients and 12.6% resulted in low harm. Only 4% resulted in moderate harm, 0.1% (n=54) in severe harm and 0.1% (n=38) in death. The types of medicines associated with incidents confirmed as resulting in death/severe harm included opioids, anticoagulants, anaesthetic medicines, insulin, antibiotics, chemotherapy, antipsychotics and infusion fluids. The analysis found that over half the reported medication incidents (58%, 53 out of 92) that resulted in severe harm or death related to medicines administered by injection. 

Types of incidents

The majority of medication incidents reported to the NPSA between January 2005 and June 2006 related to medicine administration (59.3%), preparation and dispensing (17.8%), and prescribing (15.7%). The most common incidents reported were wrong dose, strength or frequency; omitted medicine; and wrong medicine. Together these types accounted for over half (57.3%) of all medication incidents reported. Other types included the wrong patient being given the medication, wrong formulation and wrong route.

The wrong dose, strength or frequency of medicine accounted for over a quarter (28.7%) of all medication incident reports received. These constituted 38% (35 out of 92) of those incidents confirmed as resulting in severe harm or death. 

Omitted medicines accounted for 17.1% of the medication incidents reported to the NPSA from all settings; the agency urges organisations to review the medicines supply chain to ensure vital medicines are available when needed. Incidents involving prescribing, dispensing or administering the wrong medicine accounted for 11.5% of those reported.

Patients at risk

The NPSA analysis showed that patients who are allergic to certain medicines and children were potentially more vulnerable to patient safety incidents than other groups. Incidents of patients being prescribed, dispensed or administered a medicine to which they are known to be allergic accounted for 3.2% of all reported medication incidents in hospitals but almost a third of these resulted in some harm to the patient.

Patients who received a medicine to which they were known to be allergic accounted for around 5% (five out of 92) of incidents that resulted in severe harm or death. In hospitals, reports of patients being given a medicine to which they were allergic most commonly involved antibiotics (mostly penicillins), opioids and NSAIDs. 

Children aged up to four were involved in 10.1% (2,081) of medication incident reports where age was stated. The NPSA analysis said this was higher than expected, given the proportion of bed days children account for. It said recurring themes in the incidents involving children include: errors in calculating doses; 10-fold dose errors; problems with injectable medicines and the use of specific medicines such as gentamicin; and children being treated in non-paediatric areas. The report stresses that it is ‘important that action is taken to reduce risk to children’, for example, by using dedicated medicines on paediatric wards or using software to help calculate doses for children based on body weight.

Two other themes were identified that could pose risks: when patients are transferred between care teams and settings; and medicines being prescribed, dispensed or administered outside of normal processes, such as doses due at night or outside the normal ward round.

Evidence from this report has been used to identify seven priority areas for action by healthcare staff and organisations (see box).

Patient safety alerts

This report (NPSA, 2007b) states that health professionals such as nurses ‘are required to help change practice to improve patient safety’.

The agency’s safe medication practice work programme for 2007-2008 consists of five patient safety alerts (NPSA, 2007a), covering five high-risk issues:

 - Anticoagulant medicines;

- Liquid medicines administered via oral and other enteral routes;

- Injectable medicines;

- Epidural injections and infusions;

- Paediatric intravenous infusions.

This programme includes five overarching strategies to minimise risk (NPSA, 2007b):

- Rationalise product ranges and use products with safer designs;

- Provide patients with better information and improve communication;

- Policies and procedures (up to date and clearly written, reflecting local circumstances);

- Training and assessment of competences;

- Implement annual medicines management audit programme.

Priorities for action

- Increase reporting and learning from medication incidents (for example, ensuring that there is a multidisciplinary group to review and learn from incidents);

- Implement NPSA safe medication practice recommendations (the patient safety alerts);

- Improve staff skills and competences (the NPSA has developed work competences for anticoagulant therapy, the use of injectable medicines and paediatric infusions);

- Minimise dosing errors (for example, by providing help for staff in the form of dosage charts and calculators);

- Ensure medicines are not omitted (healthcare staff should report all serious omissions or delays of medicines and these should be periodically audited);

- Ensure the correct medicines are given to the correct patients (for example, by reviewing incident reports on wrong medicine and wrong patient selection);

- Document patients’ medicine allergy status (for example, by auditing the frequency of incidents involving medicine allergy and the extent to which allergy status is documented).

(NPSA, 2007b).

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