The Pharmaceutical Journal
Vol 269 No 7215 p369-370
14 September 2002

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World Congress of Pharmacy and Pharmaceutical Sciences summary

How to ensure patient safety in drug use

Medication safety is a multidisciplinary issue involving pharmacists, doctors, nurses, health systems managers and patients. With these words, Dr Jim Smith, Chief Pharmaceutical Officer for England, set the scene for a pharmacy practice symposium entitled "Ensuring patient safety in drug use" on 4 September.

Dr Smith added that the prescription is the most common clinical intervention offered to patients and the scope for both clinical benefit and harm is great.

Ton Hoek (FIP general secretary, the Netherlands) explained how pharmacists could become involved in improving patient care in the medicines use process and thereby enhancing patient safety. First, commitment to lifelong learning provides an excellent basis for continual improvement. Secondly, improvements in professional practice can also be initiated through assessment of current practice. Self-assessment surveys, such as the national survey of pharmacy practice in hospital carried out by the American Society of Health-Systems Pharmacy and the medication safety self-assessment of the Institute for Safe Medication Practices, provide a general assessment of the quality of services and medicines use systems. Such surveys have identified areas and pharmacist activities in the United States that have improved the safety of medicines use. These include safe medicines storage and preparation, and screening all orders for drug interactions and allergies. Third, pharmacists need to ensure that all medicines are obtained from reputable sources and should be vigilant in identifying abnormalities in both packaging and the effects of medicines.

Mr Hoek went on to say that errors and adverse events could be reduced by various strategies. These include the establishment of standard operating procedures for prescription receipt and dispensing, and standard treatment policies and protocols to avoid confusion and reliance on memory. A second person should check the label on a medicine before it is dispensed. Trials in the US have found that bar codes on medicines for validation of medicines administration have been successful in improving dispensing efficiency and patient safety. Pharmacists should also be involved in patient medication reviews and medical rounds to ensure that patients receive the best therapy. It is also important to design procedures to make errors visible when they do occur so that they can be corrected before they cause harm (eg, pharmacists checking doctors' prescriptions before medicines are given). Systems should be in place to lessen the effects of errors when they are not detected (eg, antidotes for potentially dangerous drugs to be available to hand).

Pharmacists also have an important role in following up patients on medication (especially those on newly licensed medicines) to identify any adverse events and report these to the appropriate authorities. "Overall, pharmacists who strive to communicate effectively with patients and other health professionals who provide information and education could gain increased awareness of the patient's use or non-use of their medicines and hence of potential problems, thereby helping the patient to manage their medical condition safely and effectively," he concluded.

Dr Andrei Isaakov (World Health Organization, Switzerland) emphasised that patient safety was high on WHO's agenda. In attempting to define patient safety, he said that the safest health care environment is one where clinical care is measured and managed and the desired clinical outcome is achieved. In his view, patient safety could be defined as freedom from accidental injury, the prevention of harm and the avoidance of adverse outcomes that could result from health care rendered to the patient. How-ever, there is no commonly agreed definition for errors in health care, and this lack of standardisation of definition and terminology made interpretation of the literature difficult. "What is clear, however, is that most errors are due to system failure rather than individual failure." he said.

Although faults in the system can never be totally eliminated, there is a need to build organisations that are as safe as they can be. This means an emphasis on proactive risk assessment, openness and transparency, the need to learn from incidents and strategies to improve teamwork. "It is also important to focus on fixing systems not blaming people," he concluded.

Dr Delon Human (secretary general of the World Medical Association, France) supported the idea that system failure is responsible for medical errors. Individuals are rarely responsible, apart from a few obvious instances such as harold Shipman and those in the paediatric heart surgery cases in Bristol. "What usually happens is that separate elements combine, together producing a high-risk situation. It is therefore important to create a non-punitive culture for reporting health care errors where the emphasis is on preventing and correcting system failures and not on individual or organisation's culpability," Dr Human said.

Bad systems, not bad people

Concurring with this diagnosis, Judith Oulton (chief executive officer, International Council of Nurses, Switzerland) said that most errors occur not because people are reckless or lack training, but because organisational systems are not designed to prevent them. One US study had found that 75 per cent of adverse drug events are attributable to system failures, although other studies had shown that 50 per cent of medication errors were preventable. "It isn't a problem of bad people, but of bad systems," she said.

From a nursing perspective, system problems that allow such errors include lack of education and training, lack of quality assurance systems, lack of access to clean water and adequate supplies, and poor staffing levels.

Another issue for nurses is lack of drug information at the point of drug administration. "A nurse should not have to guess, for example, whether 20mg is the right dose of a newly released antibiotic for the woman in room 112," said Ms Oulton. Given the number of medicines, both prescribed and over-the-counter, marketed each year, and the growth in complementary medicines, there is a serious need for good references. The use of palm computers on wards is one solution.

She went on to say that improving the safety of medicines use requires a system wide effort from all players — politicians, policy makers, health care providers, patients and the public in general. Effective communication and collaboration are vital to ensure that appropriate regulation, policy and resources (including staff) are present. If communication between the nurse, pharmacist and doctor is poor, it is inevitable that opportunities for errors will increase. In addition, more attention needs to be paid to what the patient is saying, she emphasised.

Albert van der Zeijden (the Netherlands) discussed the role of the patient in ensuring patient safety. "Patient-centred health care" is a current buzz phrase, but unfortunately words are not facts, he said. True, health care systems are moving in this direction. Systems where health professionals are responsible for the well being of their clients are changing into systems where clients are responsible for their own choices and health professionals are responsible for the quality of their advice. But there is still some way to go, he added.

Better communication needed

Despite patients rights legislation, most patients cannot make fully informed choices about their health care. To achieve this, there is a need for better communication between health professionals and patients. Communication requires time, but also common ground, which means that patients have to be sufficiently informed — before seeing a health professional — to be able to articulate their concerns. Doctors are not the only valid source of health information, and, in relation to medicines, the pharmacist should be the main supplier of information. How-ever, pharmacists, like other health care professionals, should remember that the needs of the patient should guide communication with patients, not the pharmacist's expectation about what is in the patient's interest.
— Contributed by Pamela Mason.