Hospital Pharmacist
Vol 10 No 1 p4
January 2003

News summary

Related websites
Quality and Safety in Health Care abstract (more)
National Patient Safety Agency (NPSA) (www.npsa.org.uk)

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.

Dr Dean told Hospital Pharmacist: "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 should focus on teaching and awareness and should be set up alongside the safe medicines practice committees recommended by the National Patient Safety Agency (NPSA).

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 this 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.

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

Speaking to Hospital Pharmacist, a spokesperson from the NPSA said that the agency recognises that medication errors are one of the most important types of error in hospital services. The NPSA has appointed two pharmacists to develop solutions to reduce the risk of harm to patients as a result of medication errors.