The Pharmaceutical Journal
Vol 271 No 7256 p27
5 July 2003

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ECRI/Medical Protection Society

Medication errors in primary care

An "open and fair culture" was called for by Dr MAUREEN BAKER, director of primary care, National Patient Safety Agency. "We used to hear the term 'blame-free culture'," she explained. However, people were sceptical of this since blame could be appropriate, for example in criminal or grossly negligent acts. "So now we need to move to the term 'open and fair culture'. This should be achievable in the National Health Service and health care."

The role of the NPSA is to improve patient safety in the NHS, she said. It does this through capturing and analysing incidents, and learning from mistakes. It then aims to change practice and systems to reduce risk. "We have to move away from a focus on individual blame to looking at what we can learn from the system," she added.

The NPSA is collecting information on events from NHS organisations, staff, patients and carers. "The point of this is not to have the largest database in the world, although it is something it will be soon," she said. "But it is to be able to analyse incidents and determine if we can find solutions to address the error." Dr Baker cautioned that care has to be taken not to design a new system that stops one problem but introduces new errors.

Causes of errors

The underlying causes of medication errors could be divided into three areas, according to Professor TONY AVERY, professor of primary health care, University of Nottingham. These are:

• Hazardous prescribing

• Inadequate monitoring

• Issues at the primary/secondary care interface

Hazardous prescribing could result from a lack of knowledge about either the drug or the patient, but could also be a failure to use information properly. Prescribing errors could also result from failures of computerised decision support systems and "active failures" such as forgetfulness or inattention.

Professor Avery highlighted a lack of time and skills for GPs to undertake comprehensive monitoring and reviews of medication. "We need colleagues in pharmacy to help out here, particularly with more complex reviews," he said. In addition, poor systems for recalling patients to surgeries could result in inadequate monitoring.

Repeat prescribing could also lead to medication errors. He said that doctors have inadequate systems for deciding what should go on to repeat prescriptions and stressed that only appropriately trained staff should be able to initiate, alter or authorise repeat prescriptions.

Communication is a problem that leads to medication errors. This includes lack of communication between primary and secondary care, secondary and primary care and between doctors and community pharmacists. A lot of these problems are caused by not having electronic transfer of information.

"We have a crazy situation where the pharmacist, who is supposed to be in the position of monitoring and identifying errors, doesn't actually know if the patient has, for example, asthma if the prescription is for a beta-blocker," he said.

Tackling errors

The theme of medication errors occurring at the primary/secondary care was continued by Dr CATHERINE DUGGAN, director of the academic department of pharmacy, Barts and The London NHS Trust.

She undertook research to clarify discrepancies that occur at the primary/secondary care interface, and then to design and test a cost-effective intervention to prevent the errors. General medical patients were recruited in hospital and divided into a trial and control group. At discharge, patients in the trial group were given information about their drugs to take to a community pharmacy.

The study showed that for every 19 patients discharged with information, one adverse event that had a clinically significant effect could be prevented. "It is fairly cheap for provide a photocopy of information in an envelope for pharmacists," she said. "And it would cost even less if we had electronic information transfer."

Of the 47 community pharmacists who received information, 46 said it was exactly what they wanted. Only one suggested being paid to be involved. "At this level of communication, community pharmacists want to be involved but perhaps at a greater level — such as using the information to conduct medication reviews — then pharmacists would want to be paid," she commented.

Factors that increased risk of problems included the number of drugs prescribed, the number of changes to drugs and the age of the patient. Dr Duggan concluded that communication is a good idea. "I would recommend that all patients should be discharged with information."

Professor NICK BARBER, professor of the practice of pharmacy, School of Pharmacy, University of London, explained that for every one major incident, there are 10–50 minor incidents, 300–600 related near misses and thousands of occurrences of unsafe practice. However, most is known about the rare major incidents: little is known about the more common events.

All errors matter to some extent. Nearly all incidents are series of small errors, he said. "The little things matter," he stressed. "The real issue is the volume of 'not so good practice' that occurs. Trying to spot and reduce this is key."

STEVE EASTHAM, head of clinical governance, Boots the Chemists, said that creating an effective reporting system takes time and effort.

"Everyone has to understand what the aim of reporting is," he said. This is particularly the case with managers who sometimes assume a high number of reports is bad and take well-meaning but misguided action to reduce the number. This does not help develop a reporting culture.

Analysis of the incidents that occurred at Boots revealed that 87 per cent of errors were related to the selection and assembly part of dispensing, with 8 per cent in labelling and a further 5 per cent post-pharmacist check (such as the medicine being handed out to the wrong patient). Within the dispensing procedure, 31 per cent of errors were incorrect product selection, 18 per cent wrong form, 16 per cent wrong quantity and 35 per cent wrong strength.

Sources of contributing factors to errors included the process, the environment and team factors, as well as the individual. Environmental factors included dispensary size, lay-out, temperature and lighting, and distractions such as telephone calls and buzzers.

"Although the same errors often happen time and time again, repeating errors usually have different causes," he said. "In addition, most errors result from several contributing factors."

Mr Eastham concluded that behavioural change in practice is essential. "Simply telling people is not enough: increasing awareness does not produce sustained improvement."