The Pharmaceutical Journal
Vol 269 No 7206 pp76-77
13 July 2002

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European Foundation for the Advancement of Healthcare Practitioners

New initiatives to help in the prevention of medication errors

The hazard of potassium chloride concentrate is well known and a National Patient Safety Agency survey has shown that the majority of United Kingdom hospitals have no written policy and unrestricted ward stock. "Knowing about errors isn't enough. Initiatives need to happen to prevent errors," said Professor David Cousins, University of Derby, in his opening remarks. In many hospitals oral syringes are not generally available in ward areas and parental syringes are used to measure and administer some oral doses. This practice results in frequent reports of oral medicines being administered parenterally in error with serious consequences. Both examples indicate that there is no lead professional for medication safety in hospital trusts taking overall responsibility, and co-ordinating the action required to reduce and prevent medication errors.

Professor Cousins defined a medication error as any preventable event that may cause or lead to inappropriate medication use or patient harm while medication is in the control of a health care professional, patient or consumer. The Department of Health has identified reducing medication errors as an important target in the publication "Making the NHS safer for patients". There is concern that although some strategies to reduce and prevent serious medication errors are generally well known among health professionals, these strategies are still not being implemented in practice.

How the NPSA will help reduce medication errors

Laurence Goldberg, non-executive director, National Patient Safety Agency, described the new mandatory national reporting scheme for adverse health events and near misses within the NHS. The NPSA will enhance existing mechanisms for improving quality of care and promoting patient safety by harnessing learning throughout the NHS when something goes wrong. The agency will learn lessons and ensure that these are fed back to those bodies responsible for health care delivery and, where risks are identified, the agency will produce solutions to prevent harm, specify national goals and establish mechanisms to track progress.

Mr Goldberg explained the software being piloted to report incidents in three pilot communities in England with incident notification to the NPSA within three days for red (catastrophic) incidents with root cause analysis undertaken and reported within 45 days. During the pilot, 28 trusts made 27,000 reports in six months. The data were not of high quality with up to 50 per cent incomplete. Eighty-five red incidents were reported from 5 September 2001 with 10 per cent being major or catastrophic.

The vision for the NPSA is creating a safer NHS, moving from the current position of "blame the reporter" to "praise the reporter", from "keeping quiet" to "an open and learning environment" and from "safety as add on" to "integration into care, processes, education, R&D programmes and performance assessment".

Mr Goldberg said that professional and organisational silos need to change to become national and international partnerships. There needs to be team work with all involved and local quality networks. A move from from crisis management to clear management systems is also required.

"The NPSA is to promote a patient safety conscious culture. In the future we should be identifying drugs in advance and considering patient safety when buying drugs," said Mr Goldberg. "Errors impact on staff as well as patients and their families."

During a poster session at the meeting, the London Region NHS Clinical Pharmacy Service presented work they have been doing with the minimum data set used by the NPSA in its pilot. They modified the NPSA data set to ensure they received detailed information relating to medicines and collected data on errors and near misses detected by clinical pharmacy staff during their routine duties on the wards. Some 684 incidents were recorded at nine trusts in a five-day period during March 2002, mainly relating to "near misses" or medicine errors that had been picked up by the pharmacy staff before the patients was affected. The staff recording the incidents found the NPSA classifications difficult to use, which mirrored the results of the NPSA pilot, but unlike the NPSA pilot the pharmacy staff reliably completed all sections of the data set required.

Improving medicine labels and packaging

A report of the Medicines Control Agency working party on improving medicine labels and packaging was presented by Robert Calvert, a pharmacist member of the working party. He explained that the Committee on safety of Medicines (CSM) asked a working group to look at labelling on products and they found plenty of scope for improving the quality of labels to minimise the risk to patients because labelling errors account for 25 per cent of adverse events. The working group agreed that the prime function of the label was to identify the medicine, what it is for and how to use it safely. Although there is no substitute for reading the label they found there was plenty of scope for improving the quality of the label to minimise risks to patients.

A number of recommendations were made, including using a number plate approach in a field unencumbered by other information. The number plate should contain the approved or generic name, quantitative strength of product, route of administration, and that pharmaceutical form of the product. The largest size type set possible should be used for the critical information and it should be in a sans serif font, bold for emphasis and black on a white background. Positive statements only should be used.

Colour coding was not supported because of the limited number of colours available, the incidence of colour blindness and the fact that no colour coding system is able to differentiate positively between all 12,000 medicines authorised in the UK. There are 6 different colour coding systems in use by anaesthetists in theatres in the UK.

Mr Calvert said that the Association of the British Pharmaceutical Industry response was to disagree strongly on the predominance of generic names. It also said that the number plate was redundant since the required information was already clearly presented on the pack, and that company logos ensure traceability and is an aid to identification. In a press release, the ABPI said that the number plate system for medicines labelling may put lives at risk rather than saving them because the system will make the packaging of medicines look more similar, almost certainly leading to greater mistakes being made.

The CSM has agreed a set of principles to be applied when preparing and designing labelling and packaging of all components of medicines. The MCA will now work with a small group to develop a best practice guideline to use when designing labels. The pharmaceutical industry is moving forward to adopt the recommendations.

Martin Henderson, a hospital pharmacist from Caithness, asked if the recommendations would apply to ward pre-packs and was told that manufacturing units should adopt the MCA standards and the same guidelines should apply.

David Heller, a hospital pharmacist from Surrey, asked if the instruction "take as directed" should be banned. Mr Calvert said it was a clinical governance issue working with prescribers to ban this.

Sue Reid, director of nursing, Bolton, asked if we should look again at colour coding in relation to risk. Mr Calvert said that we are using colour already for eye-drops, inhalers etc, and it should be used judiciously. The lobby against colour coding was strong. The use of alerting symbols should deal with the issue.

Professor Cousins commented: "We should be purchasing for safety not just on price. The industry will sit up if products are not being bought because of the price but we are willing to pay a few pence more for safety."

The use of IT

The use of information technology in minimising medication errors was discussed by Keith Farrar, chief pharmacist, Wirral Hospital NHS Trust. He reported work at the Wirral to change the electronic prescribing system introduced in 1992 to reduce errors that are detected by pharmacy interventions. Customised changes to the prescribing pathways have restricted availability of some confusing combination products, reduced incidence of some interactions by guiding prescribers to alternative product choices and significantly improved prescribing of some problem drugs such as heparin, and in some problem areas such as paediatrics.

The introduction of automation in 2001 was originally intended to release technician time from the dispensary to ward-based activity. Research had shown that re-engineering supply of medication to the patient's bedside led to a four-fold reduction in the risk of medication administration error and that the technicians played a vital role in the management of medicines at the bedside. The introduction of automation also led to a reduction in dispensing errors due to barcode control of medication supply. This gave them a valuable pointer to the future where barcode administration will reduce administration errors to a minimum.

Complaints as a tool

Susan Lowson and Charles Butler, from the Health Service Ombudsman's office, London, discussed the use of complaints as a tool to warn of risks and improve clinical practice.

"Complaints are a fact of life — no organisation or profession can avoid them and it is not desirable to ignore or belittle them" said Ms Lowson. "Some are trivial; a few, obsessive or malicious. But most, if well handled can have positive outcomes." A description of the work of the Ombudsman's office showed that complaints in the Health Service often stem from stressful events at a time when people feel vulnerable and scared. They may at times be unreasonable but still must be assessed objectively. Complaints can also be stressful to NHS staff who may well believe they have done their best in difficult circumstances and the only outcome is for them to be criticised. Complaints departments must be able to support both the complainant and staff.

The Ombudsman publishes an annual report on cases that have been investigated by his office in order that they may be used as a tool for trusts to learn from. The report highlights the main themes that emerge from complaints and provides pointers to good practice in complaints handling.

Reducing anaesthetists' errors

Professor Alan Aitkenhead, Queens Medical Centre, Nottingham, looked at the subject of reducing medication errors by anaesthetists.

Anaesthetists have recognised the risks of drug administration errors for many years and have instigated steps to reduce the risks substantially in anaesthetic practice. The anaesthetist uses many intravenous drugs and most look the same when drawn up into the syringes. Risks can occur at several stages. Professor Aitkenhead strongly recommended that all syringes are labelled at the time the drug is drawn into the syringe. Colour coding for each class of drug can help identify the kind of drug — especially important in an emergency. A nationally agreed system of colour coding is needed. A space on the label is also needed to insert the strength and he recommends that standard concentrations are used, except in paediatrics.

The risk of error is minimised by the habitual use of different sizes of syringe for each class of drug and separation of the anaesthetic drugs from others by storing them in specific trays. Errors usually occur because of non-routine practice or when usual habits are breached. The risk of error is increased when two anaesthetists are working together when the habits of one may be different from the habits of the other

To help prevent errors, Professor Aitkenhead called for a change by the pharmaceutical industry to label in milligrams, not percentages.

High-risk environments

Preventing medication errors in high-risk environments was discussed by Dickon Weir Hughes, Royal Marsden Hospital, London. He identified high risk environments as being due to:

• Complexity of case mix (eg, beds not available)
• Staffing levels (health care assistants do have the same effect as qualified nurses)
• Types of medication given
• Trial drugs

Where teams do not interact well there is a potential problem and a risk issue. When an error is made staff support is important. Staff often say they know the procedures but still make errors and do not know why.

Mr Weir Hughes suggested an eight-point plan for prevention of errors:

1. Identify high risk areas

2. Encourage reporting and consider what happens to people when they do (encourage owning up, level of honesty, not to feel frightened)

3. Increase identification by use of internal observers (eg, a pharmacist watching a nurse administering a drug)

4. Support prescribers (computerisation, standing orders, protocols, drug information)

5. Dedicate time and resources to developing pharmacy expertise (doctors and nurses get study time; there should be equitable allocation to all disciplines)

6. Zero tolerance of badly written prescriptions

7. Reinforce nursing staff (drug administration tests, skill mix, use of research nurses; give all recruits an arithmetic test at interview as part of the selection process)

8. Introduce systematic review (doctors, nurses, pharmacists and midwives should get together and look at medication errors as a multidisciplinary issue)