Medication errors addressed in report
Examples of key recommendations
· Have clear procedures for documenting allergies
· Implement electronic
prescribing systems with automatic alerts
· Use readily distinguishable wristbands for patients with known
allergies
· Do not take oral and
intravenous drugs to a patient’s bedside at the same time
· Include details of age, weight and
the intended dose in mg/kg on all
prescriptions for children
· Standardise the range of chemotherapy infusion devices, preferably
through centralised equipment libraries, and ensure that support
and training in their use is provided for staff
· Communication about methotrexate
dose regimes should be clear and explicit, and dispensing and
prescribing computer
systems should incorporate alerts to prevent
inappropriate daily dosing
· Limit the range of opiate analgesics used in primary and secondary
care
· Have standardised charts or, preferably,
validated computer software for
calculating the doses and infusion rates for potent drugs such
as digoxin and opiates |
Strategies to reduce medication errors are set out in a report published recently by the Department of Health. The report, entitled“Building
a safer NHS for patients: improving medication”, sets out detailed
information as to the nature and causes of errors and provides empirical
recommendations and examples of current good practice designed to influence
practice at a local level. Chief pharmacists are among the report’s
stated target audience.
The report details the types of errors commonly made in the prescribing,
dispensing and administration of medicines, with pharmacists’ roles
in preventing these being recognised. In addition, the challenges associated
with specific patient groups
(eg, patients with allergies, seriously ill patients and children) and
types of medicines (eg, anaesthetic agents, anticoagulants, cytotoxic drugs,
intravenous infusions, methotrexate, opiate analgesics, and potassium chloride)
are highlighted. Organisational and environmental issues, such as improving
the labelling and packaging of drugs and enhancing communication at the
primary and secondary care interface, are also addressed. Key recommendations
are included throughout.
When announcing the report, Lord Warner, undersecretary of state for health
pointed out that: “A prescribed medicine is the most frequent treatment
provided for NHS patients, so ensuring that drug treatment is safe is key.”
The report is welcomed by the National Patient Safety Agency, an organisation
promoting many initiatives that are in line with the report’s recommendations.
According to David Cousins, head of safe medicines practice at the NPSA: “The
report will be extremely helpful to all working with medicines in the NHS.
It summarises many of the safety problems with medicine use, and provides
a focus and driver for change.”
The Royal Pharmaceutical Society has also welcomed the report, with President
Dr Gill Hawksworth emphasising the Society’s commitment to the Government’s
patient safety strategy.
The full report is available here [The DoH web address is to change –– see
p45]. |
Hospital Pharmacist