Analysts expect more serious medication errors
Systems analysts who have studied the drug distribution
system used in National Health Service hospitals have expressed surprise
that serious medication errors are not more common.
Three systems experts from University College London
(Douglas Cowper, Alan Smith and Mark Jurgens), examined the distribution
system on 1 October, along with Dr Bryony Dean (principal pharmacist,
Hammersmith Hospital), Karen Hodson (senior sister, Hammersmith Hospital),
and a doctor from the hospital (Dr Graham Neal).
Many of the issues they discussed related to the
recent move towards patient packs. The group was particularly concerned
about the use of similar packaging for different medicines produced by
the same manufacturer, and the small print used for generic names in comparison
to brand names.
Dr Dean said: “When the majority of prescribing
in hospitals is by generic name, identification of the right preparation
is fraught with potential problems. Over-labelling packs with generic
names might be one solution unless manufacturers improve their packaging.”
The group was also concerned that, for most tablets
and capsules supplied in patient packs, it is difficult to read the name
on the back of the blister strip once the tablets or capsules have been
removed. Ms Hodson was concerned that nursing staff might put blister
strips back into the wrong boxes during a drug round and that such mistakes
might not be identified. This was not considered to be an issue when tablets
are supplied in medicine bottles; although it is often impossible to identify
white tablets, it was considered unlikely that they would be placed in
the wrong bottle.
Improving standards of packaging and labelling was
considered to be the most logical place to start in the prevention of
administration errors. However, computerised prescribing was thought to
be the way forward for the prevention of prescribing errors. It was expected
that this would help prevent errors involving the prescribing of drugs
to which patients are allergic, prescribing when contraindicated and drug
interactions. It was agreed that computerised prescribing systems would
need to be carefully validated and tested, as it would be easy to introduce
new and potentially serious types of error.
The group now plans to put together proposals to
test the impact of some of these and other suggestions. One problem will
be that measuring error rates is fraught with methodological problems,
and it can be difficult to measure the impact of changes made.
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