The Pharmaceutical Journal
Vol 269 No 7228 p835
14 December 2002

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Pharmacists need a formal feedback system for reporting medication errors

Hospital pharmacists need to establish routine and formal feedback systems for reporting medication errors, according to Bryony Dean, director of the Academic Pharmacy Unit at Hammersmith Hospitals NHS Trust, London.

This recommendation follows findings of a study undertaken by Dr Dean and colleagues which suggest that details of medication errors, while picked up as part of the routine daily checking of drug charts by ward pharmacists, are often only fed back to the prescriber and not to the rest of the medical team. Speaking to The Journal, Dr Dean said: "If errors are not discussed among staff, it is not possible to study hospital-wide and national issues, or to develop strategies for their reduction."

At Hammersmith Hospitals NHS Trust, the pharmacy department has set up regular medication incident briefing sessions that allow pharmacists to discuss medication errors that have arisen within the hospital with other staff, and to come up with solutions to prevent them recurring. Dr Dean suggested that pharmacists at other hospitals could set up their own briefing sessions so that medication errors occurring locally could be discussed.

These sessions, which focus on teaching and awareness, should be run alongside the safe medicines practice committees that the National Patient Safety Agency wants to see being set up in all trusts (PJ, 9 November, p671). "Trusts need both," she said.

In the study carried out by Dr Dean, pharmacists prospectively recorded details of all prescribing errors identified in non-obstetric inpatients during a four-week period. Around 36,200 prescriptions were written during the study period, and a prescribing error was identified in 543 (1.5 per cent). One in four of the errors were considered to be "potentially serious" and likely to harm the patient. Most of the errors (54 per cent) were associated with the choice of dose. A higher error rate was found for prescriptions written during the inpatient stay (44 per cent) than for those written on admission (32 per cent) or on discharge (15 per cent).

According to the pharmacists' assessments, 39 per cent of the prescribing errors originated in the prescribing decision and 61 per cent in the writing of prescriptions.

The grade of prescriber was recorded for 482 (90 per cent) of the prescribing errors. Over half (56 per cent) of the errors were made by senior house officers. Junior house officers were responsible for 33 per cent of the errors, registrars for 10 per cent and consultants for 2 per cent. The authors point out, however, that junior medical staff are responsible for the majority of prescribing in hospital inpatients, and it is not possible to draw conclusions about the grades of prescriber most likely to make errors.

The study is published in Quality and Safety in Health Care (2002;11:340-4).

Speaking to The Journal, Anthony Cox, adverse drug reaction pharmacist, West Midlands Centre for Adverse Drug Reaction Reporting, Birmingham, said: "This valuable work demonstrates the important role of a routine clinical pharmacy service. As noted in the paper, this study may underestimate the number of prescribing errors due to individual variation in pharmacists' ability to detect, or willingness to report, errors. Future examination of the number and type of prescribing errors that remain undetected by routine pharmacy services could help improve monitoring strategies."

Mr Cox added that pharmacist support at the time of prescribing, in addition to retrospective chart review, may help prevent potentially serious errors arising.