Defining medication errors
A medication error is a preventable event that may lead to inappropriate
medicines use or patient harm. It can involve any one of the
following processes: |
prescribing
ordering
dispensing
distribution
preparation
administration
|
labelling
packaging
nomenclature
communication
education
use and monitoring of treatment
|
Action is needed to reduce the frequency of medication errors. Pharmacists
might think that they know all about the risks that can lead to medication
errors, but the message is that knowing about risks is not the same as
taking action to prevent them.
Ways in which medication errors can be tackled are described in a report
published this week by the Department of Health. “Building a safer
NHS for patients: improving medication safety” describes good practice
that can reduce risk of errors. The report is divided into chapters.
Each examines why a particular type of error occurs and makes recommendations
on how the risks that lead to these errors occurring can be reduced.
One organisation that will have an important role in tackling this agenda
is the National Patient Safety Agency. Many of the initiatives that the
NPSA is currently undertaking are in line with the recommendations in
the report. Professor David Cousins, head of safe medication practice
at the NPSA, says the report is helpful in that it brings information
about medication errors together in one place. “It helps everyone
to focus on how to achieve the Government target of reducing errors in
prescribed medicines by 40 per cent,” he explains.
|
Similar packaging and drug names can lead to
selection errors in dispensing
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The report may not contain any surprises but the fact that medication
errors still occur highlights the need for the report. “Knowing
about risk is not the same as taking risk management steps,” stresses
Professor Cousins. Proof of this comes from the work that the NPSA has
undertaken on potassium chloride in hospitals: “People said that
they knew about the risk but when we did an audit we found that, before
our alert came out, only 25 per cent of hospital trusts had put all the
safety measures in place.”
Professor Cousins suggests that all pharmacists read this week’s
report and identify the risk management controls that they have in place
to prevent the problems it identifies. Remembering that something poses
a risk is not enough — action is needed. What the report says
Reducing dispensing errors
The report makes the following recommendations to reduce the
risk of dispensing errors:
• Check the clinical appropriateness of the prescription before
dispensing
• Carry out an accuracy check of the dispensed medicine, if possible
by a second person
• Dispensing should be in line with the Royal Pharmaceutical
Society’s practice guidance
• Staff should be suitably trained and demonstrate competence
to dispense and, if appropriate, to carry out the final check
• Dispensing errors and near misses should be reported through
the NPSA national reporting and learning scheme by all pharmacists
• Environmental conditions in the dispensing area should support
safe practice, and minimise fatigue and distractions. Facilities
and staff should be appropriate for workload
• Use the Society’s HELP mnemonic for accuracy
checking
How much has been dispensed
Expiry date check
Label check
Product check
• Labels should be read at least three times – on selection,
labelling and issue – to confirm the drug name, strength
and formulation
• The patient’s or carer’s understanding of the medicine
should be checked on issue |
Errors that can occur in the medication process — this includes
the prescribing, dispensing and administration of medicines —are
described in depth. The report points out that many dispensing errors
are a result of drug name confusion, failure to clarify an ambiguous
prescription, similar packaging or a lack of a check by a second person.
Other common causes of dispensing error include inexperienced staff,
low staffing, transcription errors and high workload. The report says
that the top 10 drugs most often involved in dispensing errors are prednisolone,
MST, isosorbide mononitrate, warfarin, aspirin, lisinopril, carbamazepine,
diclofenac, co-codamol and flucloxacillin. How dispensing errors can
be reduced is described in the Panel (right).
Pharmacists’ roles in preventing errors in the medication process
are much wider than just dispensing. Providing advice and clarifications
about drugs to other health professionals and patients is highlighted
several times in the report. Suggested system changes in hospitals include
withdrawing high-risk drugs from ward stock and for the pharmacy to dispense
them against individual prescriptions. Another suggestion is for medicines
to be stored on wards by BNF category to minimise selection errors. In
terms of reducing prescribing errors, the report states that the instruction “as
directed” should never be used on prescriptions.
Certain patient groups and drugs represent particular challenges in reducing
the risk of medication errors. The report examines these individually.
In terms of specific patient groups, it looks at people with allergies,
seriously ill patients (in particular, drugs being administered by the
wrong route) and children. It also examines specific groups of medicine:
drugs in anaesthetic practice, oral anticoagulants, cancer chemotherapy,
intravenous infusions, methotrexate, opiate analgesics and potassium
chloride injection.
It is known that packaging and labelling of medicines can increase the
likelihood of a medication error occurring. Similar packaging can lead
to incorrect selection of a product and similar drug names can cause
confusion. So the report highlights the importance of correct, legible
labelling. “Where medicines are prescribed by brand name, the dispensing
label should also include the generic name,” it says. Problems
with splitting blister packs are recognised. Where possible, blister
packs should be dispensed in the manufacturer’s original packaging
and blister strips should not be cut during the dispensing process in
such a way that important labelling information is removed, the report
says.
The interface between health care settings is known to be a danger point
when it comes to errors. So it is not surprising that the report recommends
that reviews of medication are needed at admission and discharge from
hospital, and by the primary care team after discharge. It also recommends
providing a copy of the discharge prescription to the patient’s
community pharmacist. “Ideally, communications should be electronic,
transferring information between hospital prescribing systems and GP
and pharmacy systems,” it states. In the short term, paper-based
systems should be improved, perhaps through the use of
patient-held records. The report points out that modern IT systems will
contribute significantly to improving patient safety when they are introduced.
However, there is plenty that can be done to tackle risk management now,
and pharmacists can start by undertaking a review of their current practice. |
The
Pharmaceutical Journal