The Pharmaceutical Journal
Vol 279 No 7473 p396
13 October 2007

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Regulators, companies and safety groups need to collaborate more

Medicines regulators should work more closely with pharmaceutical companies and patient safety organisations to reduce medication errors, patient safety experts told a conference held in London last week.

Packaging and medicine design, names of pharmaceuticals and labels contributed to some of the 6,000 medication errors reported every month to the National Reporting and Learning System from June 2006 to May 2007, noted Bruce Warner, senior pharmacist at the National Patient Safety Agency.

One example of this was the proton pump inhibitor Losec (omeprazole) having a similar name to the diuretic Lasix (furosemide), said David Williams, clinical pharmacology lead for patient safety research at the University of Aberdeen.

In the US, a decision had been made to change the name of Losec to Prilosec but this had not happened across Europe. “When we regulate medicines, as part of the regulation process, we should check that they have been risk assessed for when they are used in practical terms by a patient,” he suggested.

Dr Warner said: “Closing the gap between what is a regulatory requirement and what we feel is a safe presentation of a product for patients is one we are working on with [the Medicines and Healthcare products Regulatory Agency] all the time but it is a fundamentally different approach. It is joining the two up that we are trying to do.”

He told participants that 70,000 patient safety reports were made each month to the NRLS. Of the 6,000 medication-related reports per month, 78 per cent came from acute trusts but only 2 per cent came from primary care, dentists and others. “When we consider that 90 per cent of health care is carried out in the community, that 2 per cent suggests a huge under-reporting,” he said.

About 55 per cent of these errors were around administration; dispensing and preparation accounted for 20 per cent and prescribing for 17 per cent. Anticoagulants were linked to 600 patient safety incidents of harm or near harm in the UK from 1990–2002.