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Don Lavoie is alcohol programme manager at Public Health England and Gul Root is lead pharmacist, Health and Wellbeing Directorate, Public Health England
More inWhite Papers  

a pharmacist dispensary shelves imageFebruary 26 2018

The Government has been advised to instigate a wide-ranging programme of action to tackle medication error and improve medicine safety. 

Included in a swathe of recommendations are calls to:

  • improve availability and sharing of patient information between different care settings;
  • equip patients and the carers with better information and encouraging them to ask about their medication;
  • improve training and education around medicines in health profession undergraduate and post-registration training;
  • improve the packaging of medicines, and to look at how medicines are named;
  • roll-out proven interventions in primary care such as PINCER (Pharmacist-Led Information Technology Intervention for Reducing Rates of Clinically Important Errors in Medicines Management in General Practices);
  • share best practice more effectively;
  • better monitor and assess medicines errors, and research into how errors can be further reduced.

The recommendations have been made by the Short Life Working Group on reducing medication-related harm. This was set up in September 2017 with a remit to advise the Government “on the scope of a programme to improve safety in the use of medicines, including how to reduce medication errors and establish the best way to measure progress.”

Its report has been published on the same day as new research has been published by the Policy Research Unit in Economic Evaluation of Health and Care Interventions (EEPRU), which was asked to review the evidence on medication errors in England.

Data from this 174-page study has been picked up in the national media with claims that:

  • an estimated 237 million medication errors occur at some point in the medication process in England per year (of which 72% have little/no potential for harm);
  • an estimated 66 million potentially clinically significant errors occur per year, 71.0% of which are in primary care;
  • prescribing in primary care accounts for 33.9% of all potentially clinically significant errors;
  • non-steroidal anti-inflammatory drugs (NSAIDs), anticoagulants and antiplatelets cause over a third of hospital admissions due to avoidable adverse drug reactions (ADRs);
  • primary care ADRs leading to a hospital admission were estimated to cost the NHS £83.7 million and cause 627 deaths and contribute to 22,303 deaths;
  • secondary care ADRs leading to a longer hospital stay were estimated to cost £14.8 million, cause 85 deaths and contribute to 1,081 deaths;

“It is likely that many errors are picked up before they reach the patient, but we do not know how many,” said the researchers from the Universities of Manchester, York and Sheffield. They compiled the review analysing 36 studies.

The study notes that “there is little evidence about how medication errors lead to patient harm,” and that the researchers had to estimate burden using studies that measured harm from ADRs.

In addition, “estimates are based on studies at least 10 years old so may not reflect current patient populations or practice.” However, “this may be an underestimate of burden as only short-term costs and patient outcomes are included, and we had no data about the burden of errors in care homes.”

Health Secretary Jeremy Hunt flagged up both papers in a speech at the Annual World Patient Safety, Science & Technology Summit in London on February 23. He said that measures being taken currently that should improve openness and transparency in detecting, reporting and addressing medication errors include:

  • the decriminalisation of dispensing errors, due to come into effect from April,
  • starting to better understand the level of hospital admissions arising from prescribing in primary care
  • increasing uptake of electronic prescribing in hospitals.

Responding to the reports, Sandra Gidley, Chair of the Royal Pharmaceutical Society’s England Board said it was “essential that the Secretary of State and the health professions build a culture of transparency and openness. This will play a significant role in reducing medication errors.”

She said that closer collaboration between GPs and pharmacists to improve prescribing makes care safer. She also called for more pharmacist access to the patient record. “This latest research underlines the importance of pharmacists having access to vital information from a patient's record to enhance safety. We now need to build on this by enabling pharmacists to update a clinical record with details of any treatment they provide,” she said.

“Patients who move in and out of hospital and other settings are at high risk of medication errors as the right information about medicines is often not transferred with them. Pharmacists can and have been playing a vital role in reducing medication errors through transfer of patients between care settings. We strongly believe that every care home should have a named pharmacist dedicated to improving medicine safety.”

The General Pharmaceutical Council welcomed the proposed measures to improve patient safety. “Pharmacy professionals will play a critical role in delivering these new measures and, as the pharmacy regulator, we want to play our part in supporting pharmacy professionals to do this,” said the GPhC’s chief executive, Duncan Rudkin. “We will be carefully considering the recommendations of the working group, including in relation to training in safe and effective medicines use within initial education and training and continuing professional development.

“We strongly agree with the Secretary of State that it is vital to have a learning culture across healthcare. We will continue our work to promote a culture of openness, honesty and learning across pharmacy, and we will be urging everyone who employs pharmacy professionals or works within pharmacy to do the same.”

The National Pharmacy Association has warned that, in light of the studies’ findings and recommendations, the Health Secretary should rule out the prospect of allowing dispensing technicians to supervise the supply of prescription medicines.

An NPA spokesman said: “Community pharmacists are the last line of defence against medication errors, dispensing more than a billion prescription items each year and clinically checking each one. They use their professional judgement and expertise to query about 6.6 million of those items, helping avoid many incidents that might otherwise have resulted in serious harm.

“Pharmacy technicians are a valued part of any pharmacy team but it’s hard to see how removing medicines experts from the supply process can improve patient safety.”

Links:
DHSC announcement   
DHSC. ‘The Report of the Short Life Working Group on reducing medication-related harm’. February 2018            
EEPRU report – R Elliott et al. ‘Prevalence and Economic Burden of Medication Errors in The NHS in England. Rapid evidence synthesis and economic analysis of the prevalence and burden of medication error in the UK’. Policy Research Unit in Economic Evaluation of Health and Care Interventions. Universities of Sheffield and York. 2018          
RPS statement
GPhC statement          
NPA statement

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