The Pharmaceutical Journal
Vol 268 No 7200 p777
1 June 2002

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British National Formulary conference

Medication errors are still too frequent, says chief pharmaceutical officer

Medication errors are rare but still too frequent said Dr JIM SMITH, chief pharmaceutical officer, Department of Health. However, with over half a billion prescriptions written each year in the community and 200 million in hospitals, the sheer scale of medicines use made the occurrence of errors inevitable.

Dr Pamela Mason is a pharmacist and freelance writer from Sydenham, South London

There was a perception that medication errors (which could occur in prescribing, dispensing or administration) were increasing, he said, but the evidence base was weak because monitoring was limited. Lack of reporting in this area was not surprising, and there was a need to promote a culture of learning, rather than one of blame. For pharmacists, the potentially blaming apparatus of the Medicines Control Agency and the Royal Pharmaceutical Society made this difficult, he said.

Facts and figures for medication errors were particularly hard to come by in primary care where, until recently, error handling had largely been driven by complaints and litigation. About one quarter of all litigation in general practice involved medication errors, but there were no data on dispensing errors in the public domain. In secondary care, there were good data from research studies which showed that errors occurred typically in 4 to 5 per cent of drug administrations of which about 1 in 1,000 caused serious harm.

Putting this in context, one estimate indicated that, with a 99.9 per cent error-free medication rate, a 600-bed teaching hospital would still experience 4,000 drug errors a year. Another estimate suggested that a district general hospital might experience two or three serious errors each week.

Some causes of prescribing errors had been identified in a paper published in The Lancet earlier this year, he said. Out of 88 potentially serious prescribing errors identified in the research, 57 per cent were the result of skill-based slips or lapses (eg, adding a new drug to a chart without crossing off the old one). A further 39 per cent were made through so-called rule-based mistakes (eg, not knowing that the dose of ciprofloxacin should be reduced in renal impairment).

The Government was committed to reducing medication errors and had identified targets, including the reduction of serious errors with prescribed medicines by 40 per cent by 2005. Given that there was no accurate baseline, it was unclear how progress towards this target would be measured, Dr Smith said.

What was clear, however, was that medication errors could not be reduced by application of a single solution. A range of measures, such as enhanced reporting and dissemination, improved training, better access to information and decision support, streamlining of systems, procedures and communication, especially at the primary/ secondary care interface, together with active management in all National Health Service organisations, were required, he concluded.

The BNF

Dr ROBIN FERNER, consultant physician, West Midlands centre for adverse drug reaction reporting, Birmingham, highlighted the role of the British National Formulary in helping prescribers to be well informed, safe and effective. "To venture out into prescribing without a BNF is like travelling into Transylvania without a clove of garlic and a crucifix. In short, you need the protection," he said.

Professor MARTIN KENDALL, chairman of the BNF Joint Formulary Committee and professor of clinical pharmacology and therapeutics, Birmingham medical school, added that although the BNF was now over 800 pages long, it still fitted in the pocket. The BNF was unique it that pulled together all available information, including guidance from the National Institute for Clinical Excellence (NICE), advice from experts and the collective wisdom of its editorial staff.

Professor JUDITH CANTRILL, School of Pharmacy and Pharmaceutical Sciences, University of Manchester, said that many health care professionals did not know what was in the BNF and that pharmacy students in Manchester were trained how to use it before leaving university.

Guidelines at the point of care

A crucial issue for clinical prescribers was having appropriate prescribing guidance readily available at the point of care said Dr JONATHAN RAY, consultant chemical pathologist, Oxford Radcliffe Hospitals. Practitioners were besieged with guidelines, protocols and frameworks, some of which were evidence-based, but some of which were not. Some were generated locally; others by professional and government bodies. Identifying guidelines appropriate to the clinical context and the individual patient was a minefield.

Even with relevant, validated, evidence-based guidance, there was little chance of affecting practice without the appropriate technology to deliver the guidance, he said. Use of intranets and handheld computers to be used at the point of care could be helpful but needed to be evaluated. Moreover, embedding certain guidelines and not others in clinical computer systems could reduce pressures on staff by reducing choices, but threatened clinical freedom and altered where responsibility for clinical decision-making lay.

ETP update

Professor Sir JOHN PATTISON, director of research, analysis and information, Department of Health, updated participants on the electronic transfer of prescriptions (ETP) project. Of the three consortia in the pilots Pharmacy2U was up and running and had processed its first prescriptions at the end of March. Both the Transcript consortium and the SchlumbergerSema consortium were due to start in early June and would run for six months. Evaluation would be conducted in December 2002, with a report following as soon as possible, he said.