The Pharmaceutical Journal
Vol 279 No 7475 p469-471
27 October 2007

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Drug history errors in the acute medical assessment unit quantified by use of the NPSA classification

By Stuart Rees, Peter Thomas, Ashit Shetty and Kehinde Makinde

Abstract

Aim
To determine the extent and quantify the importance of medication history errors made during the clerking of patients being admitted to an acute medical assessment unit (AMAU).

Design
A prospective study.

Subjects and setting
200 acute medical patients admitted to the AMAU at a district general hospital.

Outcome measures
Number of errors recorded, and the severity of each error as scored independently by a multidisciplinary panel using a National Patient Safety Agency risk assessment tool.

Results
A pharmacist and pharmacy technician reviewed 200 acute medical patients. 123 patients had at least one discrepancy noted when comparing the medication prescribed in AMAU with the medicines taken before admission.

A total of 234 errors were recorded with an average of 1.9 errors per patient. When assessed (independently by four health professionals) against the NPSA risk assessment tool, 185 (79%) were perceived as only of minor consequence, 46 (20%) as moderate and 1 (0.4%) as being potentially of major consequence.

Conclusion
We would advocate the use of multiple sources of information by appropriately trained personnel who are able to process the information effectively and therefore arrive at an accurate medication history.

Despite resource implications, utilising a pharmacy technician, together with a clinical pharmacist, would ensure continuity between primary and secondary care and help attain the national targets in reducing the number of serious medication errors.