The Pharmaceutical Journal
Vol 268 No 7187 p274-79
2 March 2002

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The Centre for Medication Error Prevention (www.medication-errors.org.uk)

Evaluation procedure established to reduce errors linked to new drugs

Pharmacists at Alder Hey Children's Hospital in Liverpool have developed a system to assess the risks associated with new drugs being used at the hospital.

Pharmacy staff meet every month to evaluate new drug request forms submitted by consultants, and perform a risk assessment of the new drugs that have been purchased. "The principle is that we can review all new drugs for safety, efficacy and cost-effectiveness," said Paula Hayes, principal pharmacist, Alder Hey. She was speaking at a meeting on medication errors organised by the north west region chief pharmacists group held in Liverpool last week.

The new drug risk assessment group comprises senior dispensary and purchasing staff and a medicines information representative. It reviews between 10 and 20 products each month. It also evaluates packaging and labelling — checking that critical information is present and readable. "The group is cautious of corporate branding," said Ms Hayes.

Once the group has completed a review it assigns a risk to the drug. If the group considers a drug to have a moderate or high error potential it seeks to reduce that risk. "This might include amending storage facilities or obtaining clearer product information from the manufacturer," she said.

Recently, the group had intervened in the purchasing of codeine phosphate suppositories, requested for use on the paediatric intensive care unit. Three products sourced by the pharmacy, containing 2mg, 3mg and 6mg codeine phosphate, were all supplied in identical glass containers that needed to be stored in a refrigerator. Because the doses that would be needed were low, typically 0.5mg, the group considered that the 6mg suppository was associated with too high an error potential. They therefore sourced an alternative high strength product that was packaged in a box, could be stored at room temperature, and was therefore stored separately from the other suppositories.