UK medicines information
Important potential alliance between UKMi and NPSA
The problem with the medication errors that make the newspaper headlines
is that most of them have happened before and people have not learned
from others’ mistakes, explained Laurence Goldberg, consultant pharmacist
and non-executive director, NPSA. This failure to learn from the past
and the greater use of increasingly complex technology are two major factors
which predispose to errors. He told participants that adverse events in
the NHS occur in about 10 per cent of admissions, or at a rate of 850,000
per year, and in terms of hospital costs alone, account for approximately
£2bn NHS spend.
Mr Goldberg explained that the primary purpose of the NPSA was to implement,
operate and oversee all aspects of the new national system for learning
from adverse events and near misses in all sectors of the NHS. As such
it would have four major roles:
- Collect and analyse information
- Assimilate other safety-related information from a variety of existing
reporting systems
- Learn lessons and ensure they are fed back
- Where risks are identified, produce solutions, specify national goals
and establish mechanisms to track progress
In defining the limitations of the NPSA’s role, Mr Goldberg explained
that it would not have any inspection or enforcement agency function.
He also explained that at present the agency represented England and Wales
only, but that it was hoped to become a UK-wide body after consultation
with colleagues in Northern Ireland and Scotland.
“Within a few years, we want the NPSA to be the beacon for patient
safety worldwide” he said.
Improving medication safety
“It is conventional to talk about medication errors, but we should
be more positive and talk about medication safety,” said David Cousins,
head of safe medication practice, NPSA. He advised participants to differentiate
between safe and effective medicines and the safe and effective use of
medicines. The former is the traditional realm of medicines information
services and others who evaluate medicines such as the National Institute
for Clinical Excellence and the Medicines Control Agency, but the latter
is the remit of the NPSA. “As far as the safe and effective use of
medicines is concerned there are no systems, little evidence, few standards,
little learning and hardly any local committees” he said. The NPSA
hopes to establish national and local systems for learning, standards
and research evidence.
The NPSA will establish a national reporting system involving NHS trusts,
practitioners, carers and patients, he said. It will be a two-way process
in which these groups can report incidents to the NPSA, but they will
receive feedback from the NPSA as well. In addition, the NPSA will work
with similar bodies in other countries, and organisations such as the
MCA, the Commission for Health Improvement and the NHS complaints department.
He explained that it was important to learn from what other organisations
were doing and took the opportunity to highlight a variety of websites
of potential assistance to those interested in the field (see www.pjonline.com/links).
“All of this will require considerable organisation nationally and
in the medicines field. The communication systems in UKMi are second to
none, so there is an important potential alliance here between UKMi and
the NPSA” he said.
Mr Cousins suggested that NHS trusts should consider establishing local
safe medication practice committees, in the same way that most had created
prescribing or formulary committees. These would function to review local
error reports systematically and ensure safe practices are developed and
adopted. In his former role as chief pharmacist, he had set up a committee
in Derby and shared with participants some of the committee’s achievements,
which included an oral syringe policy to prevent inadvertent administration
of oral syrups intravenously, promotion of a separate prescription form
for anticoagulants because of the requirement for regular monitoring and
dose adjustment, an intravenous infusion checklist record form, audit
of records of patient drug allergies, and a policy for restricting access
to high dose opiates.
Nurses and pharmacists are good at reporting medication errors, but persuading
doctors to participate in safe medication systems can be more difficult.
Mr Cousins reported on a system in Australia where doctors can phone to
register a medication error. “This cuts down on all the paperwork
and form-filling from their point of view,” he said “and it
could be a future role for medicines information centres.” Doctors
can also be encouraged to adhere to agreed policies by asking them to
sign individual copies.
Medicines information departments have a role to promote and support safe
medication practice in all its activities. They can identify and disseminate
relevant current awareness information from the medical literature and
from professional networks, and provide information on audit methods and
their results. When new medicines are considered by local formulary or
prescribing committees, medicines information departments should flag
up safe practice implications as part of the evaluation process.
Mr Cousins ended his presentation with an appeal for pharmacists to help
the NPSA: “The NPSA can only be effective if it gets the data about
what is happening in the real world. We want to be notified of any concerns
now to help us set up reporting systems and identify future work.”
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