How medication errors can be avoided
A new Department of Health report examines ways that medication errors can be avoided. Clare Bellingham reviews the report’s recommendations
|Defining medication errorsA medication error is a preventable event that may lead to inappropriate medicines use or patient harm. It can involve any one of the following processes:|
use and monitoring of treatment
Action is needed to reduce the frequency of medication errors. Pharmacists might think that they know all about the risks that can lead to medication errors, but the message is that knowing about risks is not the same as taking action to prevent them.
Ways in which medication errors can be tackled are described in a report published this week by the Department of Health. “Building a safer NHS for patients: improving medication safety” describes good practice that can reduce risk of errors. The report is divided into chapters. Each examines why a particular type of error occurs and makes recommendations on how the risks that lead to these errors occurring can be reduced.
One organisation that will have an important role in tackling this agenda is the National Patient Safety Agency. Many of the initiatives that the NPSA is currently undertaking are in line with the recommendations in the report. Professor David Cousins, head of safe medication practice at the NPSA, says the report is helpful in that it brings information about medication errors together in one place. “It helps everyone to focus on how to achieve the Government target of reducing errors in prescribed medicines by 40 per cent,” he explains.
The report may not contain any surprises but the fact that medication errors still occur highlights the need for the report. “Knowing about risk is not the same as taking risk management steps,” stresses Professor Cousins. Proof of this comes from the work that the NPSA has undertaken on potassium chloride in hospitals: “People said that they knew about the risk but when we did an audit we found that, before our alert came out, only 25 per cent of hospital trusts had put all the safety measures in place.”
Professor Cousins suggests that all pharmacists read this week’s report and identify the risk management controls that they have in place to prevent the problems it identifies. Remembering that something poses a risk is not enough — action is needed.
What the report says
Reducing dispensing errors
The report makes the following recommendations to reduce the risk of dispensing errors:
• Check the clinical appropriateness of the prescription before dispensing
• Carry out an accuracy check of the dispensed medicine, if possible by a second person
• Dispensing should be in line with the Royal Pharmaceutical Society’s practice guidance
• Staff should be suitably trained and demonstrate competence to dispense and, if appropriate, to carry out the final check
• Dispensing errors and near misses should be reported through the NPSA national reporting and learning scheme by all pharmacists
• Environmental conditions in the dispensing area should support safe practice, and minimise fatigue and distractions. Facilities and staff should be appropriate for workload
• Use the Society’s HELP mnemonic for accuracy checking
- How much has been dispensed
- Expiry date check
- Label check
- Product check
• Labels should be read at least three times – on selection, labelling and issue – to confirm the drug name, strength and formulation
• The patient’s or carer’s understanding of the medicine should be checked on issue
Errors that can occur in the medication process — this includes the prescribing, dispensing and administration of medicines —are described in depth. The report points out that many dispensing errors are a result of drug name confusion, failure to clarify an ambiguous prescription, similar packaging or a lack of a check by a second person. Other common causes of dispensing error include inexperienced staff, low staffing, transcription errors and high workload. The report says that the top 10 drugs most often involved in dispensing errors are prednisolone, MST, isosorbide mononitrate, warfarin, aspirin, lisinopril, carbamazepine, diclofenac, co-codamol and flucloxacillin. How dispensing errors can be reduced is described in the Panel (right).
Pharmacists’ roles in preventing errors in the medication process are much wider than just dispensing. Providing advice and clarifications about drugs to other health professionals and patients is highlighted several times in the report. Suggested system changes in hospitals include withdrawing high-risk drugs from ward stock and for the pharmacy to dispense them against individual prescriptions. Another suggestion is for medicines to be stored on wards by BNF category to minimise selection errors. In terms of reducing prescribing errors, the report states that the instruction “as directed” should never be used on prescriptions.
Certain patient groups and drugs represent particular challenges in reducing the risk of medication errors. The report examines these individually. In terms of specific patient groups, it looks at people with allergies, seriously ill patients (in particular, drugs being administered by the wrong route) and children. It also examines specific groups of medicine: drugs in anaesthetic practice, oral anticoagulants, cancer chemotherapy, intravenous infusions, methotrexate, opiate analgesics and potassium chloride injection.
It is known that packaging and labelling of medicines can increase the likelihood of a medication error occurring. Similar packaging can lead to incorrect selection of a product and similar drug names can cause confusion. So the report highlights the importance of correct, legible labelling. “Where medicines are prescribed by brand name, the dispensing label should also include the generic name,” it says. Problems with splitting blister packs are recognised. Where possible, blister packs should be dispensed in the manufacturer’s original packaging and blister strips should not be cut during the dispensing process in such a way that important labelling information is removed, the report says.
The interface between health care settings is known to be a danger point when it comes to errors. So it is not surprising that the report recommends that reviews of medication are needed at admission and discharge from hospital, and by the primary care team after discharge. It also recommends providing a copy of the discharge prescription to the patient’s community pharmacist. “Ideally, communications should be electronic, transferring information between hospital prescribing systems and GP and pharmacy systems,” it states. In the short term, paper-based systems should be improved, perhaps through the use of patient-held records. The report points out that modern IT systems will contribute significantly to improving patient safety when they are introduced. However, there is plenty that can be done to tackle risk management now, and pharmacists can start by undertaking a review of their current practice.
Citation: The Pharmaceutical Journal URI: 20011072
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