The Pharmaceutical Journal
Vol 268 No 7190 p392
23 March 2002

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Leading role for pharmacists to reduce drug errors and improve patient safety

Last summer the National Patient Safety Agency was set up to help reduce the high numbers of incidents and errors that bedevil the NHS. Olivia Timbs examines the progress of the agency and finds that pharmacists are to take a leading role in its work

Related websites
National Patient Safety Agency [www.npsa.org.uk]

Within the next two months, the first "patient safety alert" is expected to be issued, one of many small steps designed to help reduce the estimated 850,000 incidents and errors occurring every year in the National Health Service.

Pharmacists barely need reminding that many errors lead to unnecessary stays in hospital or even disability or death, as well as costing the NHS millions of pounds.

Lord Hunt, who spoke to the All Party Pharmacy Group on 20 March, says that improving patient safety is a major Government priority. "If properly addressed, it will reap tremendous benefits both in terms of a reduction in unintended harm to patients and a reduction in unnecessary financial costs associated with such harm," he says.

Nearly two years ago the Government accepted 10 major recommendations made in the report "Organisation with a memory". This report revealed that one important reason why errors are made time after time is because there is no systematic way of identify problems, learning from them and avoiding them in the future.

As a result the Government created the National Patient Safety Agency (NPSA) in July 2001 to fill that gap and to launch a national reporting system for recording and learning from errors, adverse events and near misses across the NHS. And the primary purpose of the NPSA is to implement, operate and oversee all aspects of the new national system across the NHS. The NPSA will also focus on identifying the underlying causes of why things go wrong.

As Steve Wedgwood, director of communications for the NPSA says: "In many instances the root causes of adverse incidents are in the management and organisational systems supporting the care delivery. Poor communication, faulty equipment, inadequate training, a lack of information or a poor physical environment can all contribute."

The reporting system, which has been piloted and evaluated across 28 acute and primary care trusts in England and Wales, is due to be rolled out across the NHS from next month.

The NPSA board will meet on 10 April to discuss the findings from the pilot. Mr Wedgwood believes that, as a result of those discussions, the NPSA will be in a position to produce its first guidance — or patient safety alert — in May (along the lines of drug and device alerts already issued by the Medicines Control Agency and the Medical Devices Agency). A patient safety alert will, in effect, warn health care professionals that an error has been identified that must be avoided.

Laurence Goldberg, fellow of the Royal Pharmaceutical Society and one of the 12 non-executive directors of the NPSA, says that one priority is to determine the extent of medication errors. NPSA estimates suggest that between 12 per cent and 20 per cent of all NHS incidents are related to medicines.

But, Mr Goldberg says, there is no hard evidence on how the percentage divides between prescribing, dispensing and administration errors, partly because of definition. "If a pharmacist in a hospital dispensary queries a prescription that is subsequently amended, it might be logged as an error. If a clinical pharmacist makes a similar suggestion during a ward round with a consultant, the matter is seen as part of the clinical process," he explains. "This is why it is important to determine the baseline for medication errors."

Extensive studies in non-medical areas have shown that unintentional errors rarely have a single cause. Rather there is a complex set of factors involved that might include human behaviour, environmental factors, technological factors or weaknesses in procedures and the organisation involved. For this reason the NPSA has also appointed Jeremy Butler, chairman of the Royal Aeronautical Society and a pilot for 30 years, as a non-executive director to bring his knowledge of the air industry and its experience of reporting and dealing with plane crashes and near misses to the party.

Mr Goldberg expects that some of the recommendations to reduce medication errors that the NPSA will make in due course will relate to drug names that look and sound alike, the use of electronic and automated systems in hospitals and the use of standardised bar-coding on all packaging.

The NPSA has been given £20m over three years to achieve its targets (£15m for 2002–03) and is looking to appoint about 100 staff by the middle of the year. Mr Goldberg is particularly pleased that the NPSA is about to appoint two pharmacists to senior positions. The posts, advertised for the first time in this week's issue of The Journal, are for the Head of Safe Medication Practices and for the Community Pharmacist, Safe Medication Practices. "These posts, which carry high salaries, will be among the top 20 per cent of appointments to be made by the NPSA. It is an acknowledgement that the NPSA takes the input from pharmacists seriously," he adds.

At the moment the NPSA remit only covers England but there are proposals for it to cover the whole of the United Kingdom.

As Mr Wedgwood says, promoting and developing a new more safety conscious culture across the NHS and across all professions and organisations will be both challenging and exciting.

It will also require a massive commitment by staff to consider patient safety and risk assessment and management not as an "add-on" but rather as an integral part of what they do. As Lord Hunt says: "The NPSA is an organisation you can turn to for help, and one that will provide timely and relevant feedback on key patient safety issues that will assist us all in our efforts to improve safety and quality in the NHS."

This, says Mr Goldberg, means that the development of an awareness of patient safety will ultimately have to start at the undergraduate level for all health care professionals and be integrated into the curriculum.

Information on the NPSA is available on www.npsa.org.uk or tel 0207 868 2203.