Health Service Focus


Medication errors: ‘Don’t fear the numbers’

Source: NHE Nov/Dec 15

David Stevenson looks into medication errors in the NHS.

In the last three years more than 500,000 medication errors were reported by NHS organisations to the National Reporting and Learning System (NRLS), according to data obtained by NHE through the Freedom of Information Act. 

Nearly a quarter of a million of these errors occurred in the administration or supply of a medicine, and over 100,000 errors happened in the prescribing and preparation of medicines in all locations or when they were being dispensed in a pharmacy. 

When put into context, however, these figures are small. For example, there are a billion prescriptions issued every year in primary care; 2.5 million doses of medicines are administered each year in the average acute hospital; and 500,000 inpatient prescriptions each year in the average acute hospital. 

But why are the reporting figures still relatively high, and how severe is the risk? 

Of the 176,137 incidents in England reported to the NRLS between 1 April 2014 and 30 March 2015 marked as a ‘medication’ incident type, 87.6% resulted in ‘no harm’ and 10.3% resulted in ‘low harm’. 

Only a tiny proportion of the errors were severe or resulted in death. 

Talking to NHE about the figures, Steve Williams, medical safety spokesperson for the Royal Pharmaceutical Society (RPS), told us that “things still do go wrong”. Though he added: “Healthcare is complex. Because patients are living longer, they have more and more disease states, meaning they are on more and more medicines.” 

He added that there is a lot of subtlety and complexity within medicines, and the health sector is now beginning to learn that what drives a lot of the errors is “human factors”. 

“We are all human and we will, unfortunately, make mistakes. It is all those human factors and interruptions and disruptions and distractions that cause things to go wrong,” said Williams. “Although people find it a little perverse, more reporting overall is what we want. That is what the NHS is actually looking for.”

Taking action 

With the support of evidence gathered from NRLS reporting, NHS England has issued eight patient safety alerts related to medication errors since the launch of the National Patient Safety Alerting System in January 2014. 

These alerts have highlighted risks so that action can be taken by all NHS providers in England to prevent them. They have raised awareness of guidance or put steps in place to improve medication safety. 

Dr Mike Durkin, NHS England’s director of patient safety, told NHE it is vital that NHS providers are open and honest about errors and mistakes so lessons can be learnt. 

“Thanks to staff raising incidents via the NRLS, we are able to identify risks and, where appropriate, take action at a national level to improve patient safety,” he said. 

Reiterating this message, Williams added that trusts reporting more tells the NHS that they have a “better safety culture” in place. 

“As we report more we learn more. And, therefore, organisations become safer as a consequence,” he said. “People should not be fearful of the fact that the number of reports appear to be going up because the numbers are still tiny in relation to the context of how much prescribing and administering goes on.” 

NHE was told, however, that the system doesn’t want to start seeing huge increases and, ideally, wants to see “reductions in the very high risk medicines”. 

With organisations being asked to report more, as encouraged by the Care Quality Commission, the numbers could continue to rise for some time. 

“But people should not be fearful of the numbers,” he said. “What is behind [the increased reporting] is that we discover what the system issues are and then together multidisciplinary teams of doctors, nurses and pharmacists, can fix those things.” 

Greater openness 

Our FOI findings revealed that 509,980 (91%) of the 558,811 medication errors were reported by NHS trusts. 

The trusts with the highest error recording rates during the three-year period included the Dudley Group NHS FT (9,211), Nottingham University Hospitals NHS Trust (8,647), Wirral University Teaching Hospital NHS FT (7,783) and University Hospitals of Leicester NHS Trust (6,975). 

Dr Keith Girling, divisional director and chair of the Medicines Governance Committee at Nottingham University Hospitals NHS Trust, told us that the trust remains in the top 25% of reporters of patient safety incidents to NHS England via the NRLS. 

“The NRLS state that a high reporting rate should not be interpreted as an unsafe organisation and may actually represent a culture of greater openness,” he said. “We are committed to improving patient safety and actively encourage staff to report patient safety and medication incidents. 

“In the last financial year 92% of medication incidents reported at our hospitals resulted in ‘no harm’ to patients, with 7% rated as ‘low’ and less than 1% rated as ‘moderate’. No patients were judged to have suffered a ‘severe’ level of harm. Our reporting numbers and level of harm are consistent with other similar sized organisations.” 

Dr Girling added that as a trust, Nottingham acknowledges when things have gone wrong, learns from its mistakes and takes appropriate action to ensure improvement. 

“We have a well-established multidisciplinary medicines safety group which identifies medicines hazards and facilitates actions to reduce the likelihood of medicines-related harms,” he said. “We have also developed a range of tools to support staff including our Being Open (Duty of Candour) Policy, regular trust-wide updates on medicines matters, an annual ‘talk about medicines’ week and revised prescription charts to allow staff to highlight concerns and actions taken.” 


Savings and IT adoption 

Earlier this year, Lord Carter’s Review of Operational Productivity in NHS providers suggested that around £1bn per year could be saved from improved hospital pharmacy and medicines optimisation. 

Medicines are the most frequent healthcare intervention. In 2012-13, expenditure on hospital medicines was over £6.5bn, accounting for 36.5% of total NHS medicines expenditure. 

Lord Carter said: “Optimising the use of medicines is recognised as a key role undertaken well by pharmacy teams which can lead to better outcomes, including improved safety whilst reducing waste and getting consistent, best clinical practice, thereby reducing variance and improving patient care. 

“A wide range of approaches are already employed to deliver best value for money for medicines but there is a considerable amount of variation in the provision of hospital pharmacy services across the country.” 

He added that the greater uptake of the use of electronic systems for medicines procurement may also reduce the variation in stock holding levels between providers. 

But the Labour peer did note that one thing has become clear: “There is no single initiative that will deliver major efficiency savings in the pharmacy and medicines area. Rather, system-wide changes, including the use of a series of decisions and smaller initiatives…combined can make a significant contribution to the efficiency challenge when effectively shared across the wider NHS.”

Preventable harm 

Hugh Alderwick, senior policy assistant to the CEO and Integrated Care Programme Manager at The King’s Fund, recently wrote in a blog that while the overall picture is murky, it’s clear that many patients experience preventable harm across the NHS, whichever estimates we take. 

“Common examples include things like falls, venous thromboembolism, medication errors and adverse drug reactions,” he said. “As we set out in our recent report, ‘Better value in the NHS’, in each of these areas the NHS has significant opportunities to reduce harm done to patients while saving money from doing so. And as in all other areas of healthcare, there are significant variations between different NHS organisations in delivering safe care hidden within the overall picture.” 

NHS England has established a national network of medicines safety officers with representation from every NHS trust in England. This network hosts forums, conferences and regular webinars around safety issues to share best practice and improve safety. 

And, additionally, as set out in the response to the Mid Staffordshire NHS FT Public Inquiry, the National Quality Board (NQB) has published a ‘Human Factors in Healthcare Concordat’ signed by its member organisations and other partners. 

The Concordat demonstrates the NQB’s commitment, on behalf of the health system, to embed a “recognition and understanding of human factors across the NHS and in their activities, reflecting the value it can offer in respect of improving the quality and productivity of services to patients”. 

Situational awareness 

In understanding human factors, Williams told us that everybody is going to be taught to be self-aware about distractions. “It is already happening. People go into virtual labs, which is all about situational awareness,” he said. 

Discussing the role IT and technology can play in reducing medication errors, Williams said that it can be great in making the system foolproof. 

“Unfortunately, like anything, it is not a panacea,” he said. “Electronic prescribing systems are being put into more hospitals across the NHS.”

By April next year, half of hospitals are expected to have agreed to implement electronic prescribing systems. “But it is a massive culture change from prescribing and administering on paper to moving to an electronic system,” Williams told us. “They can completely cut some error types, but like anything, all actions have a reaction. What we find, and what the literature tells us, is that to begin with you can get a different type of error from the electronic system.” 

Compared to a decade ago, people now understand far more the factors behind errors. “But that is only because people have been encouraged to report incidents,” he said. “Organisations work really hard now on trying to encourage people to report errors, so we can learn and often come up with solutions. 

“We are in 2015 and, undoubtedly, going forward IT can bring benefits for trying to reduce harm for patients from medicines.”

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