Reported drug errors increase, says NPSA

The incidence of reported drug errors leading to avoidable deaths and patient harm is on the increase, according to a new National Patient Safety Agency report.

New figures from the agency show that drug errors caused at least 37 deaths and 63 cases of severe harm in 2007. The figures come in the report ‘Safety in doses: improving the use of medicines in the NHS’.

In total, more than 200 patients every month require further treatment or die because of mistake are made with their medication. Around 80m prescriptions are given out in England every year.

The report suggests the rise of reported incidents is due to better reporting rather than an increase in incidents of harm occuring.

The most common problems involved an unclear or wrong dose or wrong frequency, the wrong medicine being given, mix ups in patient names, and drugs being omitted or delayed.

The examples of drug errors given by the NPSA include an anti-coagulant drug being given to someone with a similar name to the patient it had been prescribed for, a patient receiving a strong sedative instead of insulin, and a patient receiving 10 times the prescribed dose of morphine.

The review’s main conclusions found the most serious incidents were caused by medicine administration (41%), followed by prescribing (32%).

In 2001, an Audit Commission report on medicines safety called ‘A Spoonful of Sugar’ called for the introduction of hospital electronic prescribing systems to be made a priority. It argued this would improve the safety of drugs prescribing, administration and management; yet few hospitals have such systems in place.

The 2001 report said hundreds of patients die or are harmed every year as a result of avoidable drug and medication errors. E-Prescribing was included in the £12.7 billion National Programme for IT in the NHS, but has become one of the clinical areas the programme has struggled to deliver on.

The national programme has focused on the electronic transfer of prescriptions from GPs to pharmacists, rather than on the more complex environment of hospital prescribing, medicines management and associated intelligent decision support.

Multi-year delays to NPfIT have also contributed to just a handful of trusts making widespread use of such technology to improve patient safety.

However, the NPSA report makes clear that e-prescribing and monitoring systems are no simple panacea and can introduce new risks to patient safety.

University Hospitals Birmingham NHS Foundation Trust has spent almost 10 years implementing an e-prescribing system. The trust’s medical director, Dr David Rosser, told the Guardian: "It has reduced the more serious errors by about 60% by questioning doctors and nurses when they seek to prescribe and administer treatments which the computer recognises as potentially dangerous.

"I am disappointed that these technologies are not more widely available in the NHS because they protect patients."

Gillian Cavell, consultant pharmacist at King’s College Hospital NHS Foundation Trust said: “This report highlights the fact that serious medication errors can happen in any trust.

"Existing guidance from the NPSA is helpful in emphasising the fact that trusts need to remain aware of the risks associated with medicines. We all need to follow these recommendations and implement new systems if necessary to ensure that we remain compliant with the guidelines at all times."

Overall the NPSA says the number of errors reported has jumped from 36,335 in 2005 to 86,085 in 2007. But the agency believes only 10% of errors are reported, suggesting almost a million errors may be occurring every year.

The vast majority of these errors, an estimated 96%, result in little or no harm to patients.

Martin Fletcher, chief executive of the NPSA, said: "Millions of medicines are prescribed in the community and in hospitals across England and Wales each day – the majority of these are delivered correctly and do exactly what they are meant to do.

"However, when an incident does occur, it is vital we learn from this to ensure patients are not harmed."

Norman Lamb, the Liberal Democrat health spokesman, said: "Settling claims for damages costs the NHS nearly £1 billion per year which could be spent on patient care. He said it was vital that the NHS have robust systems in place that “minimise risks and prioritise patient safety."

Link

Safety in doses: improving the use of medicines in the NHS

A Spoonful of Sugar