The Pharmaceutical Journal
Vol 268 No 7204 p921-923
29 June 2002

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European Foundation for the Advancement of Healthcare Practitioners

Medication errors and patient safety — the technician's role

Opening the meeting, the chairman, Professor Ron Purkiss, chief pharmacist, Northern General Hospital, Sheffield, said: "Medication errors — we don't know how big the problem is or even what we are looking at." Studies from the United States studies indicate that medication errors cause harm to 1 to 2 per cent of patients. A Norwegian study investigated 932 deaths and found 9.5 deaths per 1,000 were directly or indirectly the result of an adverse drug event. A recent UK study reported 88 potentially serious prescribing errors detected by pharmacists in a 550-bed teaching hospital. In the UK, we do not know how many patients are harmed by medication due to inadequate recording and reporting of events, he said.

Errors prolong the length of stay and increase expenditure on patient care. Over 50 per cent of medication errors are preventable and pharmacy staff have a key role to play in their prevention, detection, reporting and in changing practice to avoid them. Medication management systems are essential to this process. Professor Purkiss encouraged technicians to put into practice what they learnt at the meeting.

Building a safer NHS

"Errors are common and preventable. Everyone has a role to play in their prevention and the Government is committed to reducing medication errors," said Gillian Cavell, principal pharmacist, Department of Health and King's College Hospital, London. The document, "Building a safer NHS", mentioned a mandatory reporting system for medication errors with targets set, including the eradication of deaths due to spinal injection and the reduction of medication errors by 40 per cent by 2005. "The problem is we don't know what 100 per cent is yet. We have no baseline data," she said.

Risk management can be used since many mistakes are preventable and we are talking about things that have happened that should not have, eg, 13 deaths from vincristine errors. We do not know how often medication errors occur; people are afraid to report them. The only data we have are from small studies that are not generalisable.

The purpose of the National Patient Safety Agency (NPSA) is to improve patient safety by reducing risk of harm and to promote research. If the NPSA encourages reporting, then the amount of errors coming to light should increase, and the NHS will need to manage patients' interpretation.

Why and how things go wrong

"No matter how knowledgeable or careful we are there will always be situations in which errors are possible or even likely. It is usually due to human error," said Professor David Cousins, chief pharmacist, Acute Hospitals Trust, Derby. Human error has been defined as a generic term to encompass all those occasions in which a planned sequence of mental or physical activities fails to achieve its intended outcome and when these failures cannot be attributed to the intervention of some chance agency. The causes of errors were classified as skill-based, rule-based and knowledge-based, and could be due to slips and lapses, deficiencies or failures in judgement. Interruptions, application of bad rules and misapplication of good rules are also identified as common causes of errors.

Professor Cousins said: "We must think 'when something goes wrong', not 'if something goes wrong'. Double checks will help to trap the error before it reaches the patient. We should minimise the consequences of the error when it cannot be eliminated. We talk about medicines being economic, effective and safe, but this needs to be turned around to safe, effective and economic.

Risk management

"Managing risk in pharmacy practice is essential for good quality patient care. Risk must be managed throughout the medicines management chain, ie, procurement, stores, picking, dispensing, manufacturing, drug information, etc. It needs a champion, and technicians are the right people to lead on it for their area." said Margaret Ledger-Scott, chief pharmacist, South Durham Trust.

Her presentation took technicians through the risk management process of identifying the risk, analysing risk, taking corrective action, sustaining corrective action and identifying similar problems with practical examples given at each stage. The importance of information sharing was stressed and the lessons learnt should be used to prevent similar problems.

A plan to reduce risks was suggested, including leading on risk management, developing a structured approach to identifying causes and assessing the risk, involving everyone, encouraging blame free reporting including near misses, and ensuring feedback is given.

Benchmarking and auditing

An overview of using benchmarking and audit to measure and improve services was given by David Campbell, head of pharmacy, North Durham Health Care Trust. He described the two types of benchmarking as "performance" (in which ones performance is compared with that of other organisations) and "best practice" (which involves working with colleagues and neighbours and is more of an owned process). Both types involve comparing like with like. Both audit and benchmarking can be used to bring about action and improvement. However, measuring performance or comparing oneself with someone else does not lead to improvement unless action is taken. Requirements for success included gaining ownership, commitment, time, good management and analytical skills. Practical tips included avoiding data overload and involving others at all stages to help with analysis and interpretation.

Technicians should look for where obvious opportunities for improvement exist. They should scan for ideas and appraise options, looking for risk/safety management, human resource opportunities and cost improvements.

Recording and analysis

Dispensing errors were described by Steve Barker, dispensary manager, Northern General Hospital, Sheffield, as the wrong medicine dispensed or incomplete or improper labelling which is detected and reported after the item has left the pharmacy department. National statistics were gathered for a five-year period from 1994 through the Dispensing Error Analysis Scheme (DEAS), collecting standardised data from UK hospitals using a paper-based system.

Recently no national statistics have been gathered so an Access database was created to audit and analyse dispensing errors at the Northern General Hospital, Sheffield. The results of a one-month internal audit in 2001 showed 200 errors per 30,000 items which were picked up by checking before the item left the department. During the one-month audit 22 per cent of the errors involved wrong directions, 14 per cent wrong strength and 65 per cent were on discharge medicines. The errors increased between noon and 1pm and between 4 and 5pm, and there was a positive correlation between the number of errors and workload. Nursing staff mostly discovered errors that left the department but this year ward technicians have reported finding more errors than nurses.

Dispensing errors were described as the result of human error, with breaks in concentration being the main cause. The response at the Northern General Hospital has been to introduce a range of strategies, including limiting the range of strengths kept, introducing shelf warnings, splitting of storage areas, changing suppliers to reduce lookalike products, audit and feedback. There is also competency-based training for all pharmacists, technicians and assistant technical officers, with retraining if the personal error rate is more than 5 per month.

Recommendations included looking at skill mix, competency-based training, controlling the number of staff in training, and addressing the four factors of look-alike and sound-alike drugs, workload, inexperienced staff and transcription errors.

The industry's role

Although acknowledging that the safe use of medicines is dependent upon users reading the label carefully and accurately, Dawn Thompson, communications manager, DBL Faulding Pharmaceuticals (UK) Ltd, said the pharmaceutical industry could ultimately enhance patient safety by ensuring that all packaging is presented in a clear and concise manner.

Views on the existing designs and what the "ideal" packaging should look like were sought from customers and many months of design development followed to ensure the requirements of the regulatory bodies, their customers and internal corporate guidelines were met. Samples of the new packaging were shown at the meeting and were enthusiastically received by technicians.

Aim for zero errors

"Most fatal errors are part of a chain of events. Each member in the chain needs to be fully responsible for their area to ensure no misplaced assumptions are made about the facts put in front of them at each stage of the process. A methodical and disciplined approach to checking is needed and the key to zero errors is to simplify systems," said George Gannon, pharmacy operations manager, University College London Hospitals Business and Distribution Centre, London.

To deal with the 2.3 million packs handled in the distribution centre each year, the 10 non-pharmacy qualified staff need to be working accurately by lunchtime on their first day. "We have a culture of avoiding blame and shame in favour of retraining. When errors do occur we need to look behind the error involving all the staff in the process," he said. Reductions in the error rate from 1 per cent to less than 0.3 per cent have been achieved by introducing picking by product numbers, shelf locations and printed picking lists. The use of product handling flags highlighting short expiry dates, Committee on Substances Hazardous to Health warnings, double checking items, quantity checks, and whether a product leaflet is required has also helped to keep errors down.

The aim is to reduce the error rate further by improving 100 processes by 1 per cent and to involve all the staff in the improvements. Future developments at the distribution centre will include new product handling flags, checking audit, automation and completing the circle by involving the customers.