The Pharmaceutical Journal
Vol 269 No 7223 p671
9 November 2002

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How to ensure safe medicines practice

The pharmacist spearheading the Government’s drive to reduce the number of medication errors in the National Health Service in the next three years spoke recently about how he plans to achieve success. Debbie Andalo reports

Professor David Cousins, who was appointed head of safe medication practices at the new National Patient Safety Agency in September, wants to see every National Health Service trust establish a committee devoted to examining reports on medication errors and ultimately eliminating the errors.

Dubbed the "safe medicines practice committee" it should be multidisciplinary and meet monthly. Its key role would be to monitor reports of medical errors and produce local solutions and apply them (see Panel).

Professor Cousins, formerly chief pharmacist at South Derbyshire Acute Hospitals NHS Trust, made it clear that the committee approach was the only way forward. Speaking at the Hospital Pharmacist conference"A spoonful of sugar: recipes for risk reduction" at the Royal Pharmaceutical Society's headquarters on 31 October, he had this stark message for hospital pharmacists: "If you have not got one — get one."

If trusts respond to his call and a national committee network is established it will be a major step towards helping to meet the Government's target to reduce by 40 per cent the number of serious errors in the use of prescribed medicines in the NHS by 2005. According to NPSA figures, there are around 850,000 adverse medical incidents and errors in the NHS every year and 25 per cent of those which threaten patient safety relate to medication mistakes.

Committees in action

Around 30 hospital trusts have already set up a committee along the lines of that envisaged by Professor Cousins. One of the first, called the medicines management subcommittee, was established by Professor Cousins while still in Derbyshire.

His successor at the trust, acting chief pharmacist Tom Gray, explains how the committee works. Set up in the early 1990s, it is a subcommittee of the trust's drug and therapeutics committee to which it reports. It also has a direct route to the trust's quality assurance committee, which is chaired by the chief executive.

Its remit is to consider medicine-related errors across the trust. Mr Gray explains: "It was established as a completely separate committee because it was believed that the drug and therapeutics committee did not really have the time to look at processes. Although we focus on medicine-related errors, we do, through considering risk management, look at other kinds of errors within the trust as well."

The committee has 24 members and is chaired by the chief pharmacist. The deputy chairman is the trust's deputy director of nursing. A chief pharmacy technician for medicines management is committee secretary and takes responsibility for collating medication errors. It is also her responsibility to alert the committee to any trends in errors and to those errors which might have trust-wide implications. The committee has one consultant member and a representative from the local primary care trust. All other places are taken by senior nurses. All trust directorates are represented.

Every directorate in the trust receives an individual monthly report from the committee on the details of medicine-related errors. The directorate has the responsibility to report back and suggest solutions to prevent the errors happening again, but any final decision for change rests with the committee.

The establishment of the committee has given staff increased confidence to report errors but, according to Mr Gray, the majority of reports still come from nurses and pharmacists. He admits: "Reports from the hospital doctors are short. They still seem suspicious about reporting incidents and are reticent to report them."

Another issue which needs to be addressed is how to make the reporting system faster because at the moment it is paper-based. Mr Gray says: "One thing which prevents us closing the loop is the inability to get the data around the organisation so there are time delays because we have not yet been able to computerise the system." Despite these two obstacles, he still recommends that other trusts follow Derbyshire's example.

"If you can get people talking together and put a system or method of reporting in place it is the way ahead and it is also right within the current environment. It is good to get all these disciplines integrated and it is extremely good for the pharmacists. A committee system encourages you to achieve far more than you would be able to do as an individual."

Professor Cousins put forward his proposal for safe medicines practice committees as an example of best practice. It is not yet Government policy, but that may only be question of time.

Culture shift needed

His vision for success could, however, fail at the first hurdle unless there is a culture shift among NHS staff — including members of the medical profession — to a point where they feel confident about reporting medication mistakes.

Speaking at the conference, Professor Cousins said that it was estimated that an average 1,000-bed hospital should be getting around 100 adverse incident reports a month. Trusts should not be frightened by high numbers. "The more reports you get the better because you can create opportunities for learning."

Professor Cousins is also keen to stress that the solutions for beating medication errors have to be locally driven — from the bottom up. He warned hospital pharmacists that he does not want to receive a string of telephone calls at the NPSA asking him to solve their problems.

"People on the ground are the best people to come up with the solutions," Professor Cousins said.