IT Needed to Cut Drug Deaths

A new report by the
Audit Commission has highlighted the need to invest in IT systems to cut the increasing number of patients who die after being given the wrong drugs in hospital.

Approximately 1,200 people died last year in England and Wales as a result of the medication errors often caused by ineffective information systems and human errors – a rise of 500% over the past decade.

The Audit Commission’s "A Spoonful of Sugar" report says many of these deaths were entirely avoidable as they were a result of doctors not having the right information about the patients at hand – either because notes are illegible, incomplete or missing altogether.

Crucially it says that medicines management must form an integral part of clinical governance monitoring.

Statistics suggest than one in 10 people in hospital suffer some kind of "adverse event", half of which are preventable. The annual cost to the NHS of such medication errors is put at £500m a year.

Up to three-quarters of the errors could be eliminated through the use of computer technology and automated robotic dispensing systems – but a national approach is needed to ensure these systems are introduced concludes the report.

Further key problems include the fact that hospitals use different descriptions of medicines and the NHS does not have a common coding system for drugs and medicines, or a nationally accepted way to aggregate and audit drugs data.

The report concludes that errors are mainly caused because the prescriber does not have immediate access to accurate information either about the medicine or the patient.

Handwritten prescriptions also contribute to errors as they can be illegible, incomplete and subject to medical transcription errors. The report calls for the introduction of electronic prescribing systems and electronic patient records to be speeded up.

Although computerised prescribing and health records have been shown to eliminate three-quarters of medication errors, they are currently only used in a handful of NHS hospitals.

The report goes on to note the NHS IT strategy anticipates 35% of acute trusts to have installed electronic patient record systems and prescribing by 2002, and by all trusts by 2005. "However, progress has been extremely slow," notes the report.

"Many boards are concerned with strict financial targets and are unwilling or unable to invest money to achieve sustainable quality and cost improvements," states the report.

It calls for urgent action to put the NHS IT strategy back on track: "A national system for medicines and diagnostic codes should be commissioned across the whole NHS to support the introduction of electronic prescribing systems"

Additional recommendations include ear-marked funds and expertise to be provided to enable trusts to meet the 2005 EPR target, together with central guidance on systems specifications to make the area "a more attractive proposition to suppliers of IT and software systems".