Medicine errors still under-reported
Incidents of medication errors in NHS trusts are still seriously under-reported, according to a new report.
“A safer place for patients: learning to improve patient safety,” (PDF 1.4 MB) published by the National Audit Office this month, states that
around half of all
patient safety incidents in the NHS in which harm was caused to patients
could have been avoided if lessons from previous incidents had been learned.
Surveys of 267 NHS acute, ambulance and mental health trusts carried
out in 2004–05 found that medication errors accounted for 7.1 per
cent of all patient safety incidents reported. This figure is second
to patient falls which accounted for 31.5 per cent of reports.
The report points out that the MHRA only receives reports on drug errors
that are the result of adverse reactions to the medication and, because
of low reporting rates and the many barriers to reporting medication
errors, the true extent of serious errors in the use of prescribed drugs
is unknown.
The Chief Medical Officer’s 2000 report “An
organisation with a memory” set a target of reducing the number of serious errors
in the use of prescribed drugs by 40 per cent by the end of 2005. The
new report says that of those trusts that stated that this target was
applicable to them (mainly acute and mental health trusts), only 20 per
cent said that they had met it.
Many trusts said that this target was difficult to determine, due to
a lack of baseline data. Other common responses were that trusts were
currently in the process of putting action plans into place, or that
there were few errors in the first place, making a 40 per cent reduction
difficult.
The report says that although reporting of patient safety incidents has
improved at a local level, at a national level the progress on developing
a national reporting and learning system has been slower than envisaged
in the Department of Health’s 2001 strategy “Building
a safer NHS for patients.” It outlines a need to improve evaluation and
sharing of experience by all organisations with a stake in patient safety.
The report concludes that although most trusts have developed a predominantly
open and fair reporting culture, largely driven by the Department of
Health’s clinical governance initiatives, a blame culture still
predominates in some trusts.
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Hospital Pharmacist