Joanna Garrett, Senior Project Manager, shares her experience and knowledge of medication errors, and how her projects are working to reduce these in the West of England region.
I’m a healthcare professional and I’ve made a medication error.
Mine occurred late at night whilst working as a Paramedic. I was at the end of a long shift in a run of nights and I was fatigued. I was called, on my own, to a man in his mid-forties who had fallen at his home address in the early hours of the morning and broken his hip. He was screaming, his wife was shouting and confused (she’d just been woken up by his screaming) and getting a clear history was difficult. Perhaps you recognise some contributory human factors here which may have factored in the error I made.
Fortunately for me and my patient, mine was not a clinically significant error and no harm was caused. However, despite robust legislation and clear knowledge and understanding by healthcare professionals about the importance of accuracy, medication errors are still alarmingly common. Whilst it is thought that, like mine, in three out of four cases these are minor errors which are unlikely to cause harm, some errors can be catastrophic for patients.
In 2018 the Universities of Sheffield, Manchester and York estimated there were 237 million medication errors per year in the NHS in England, with 66 million of these considered potentially clinically significant errors. In 2017 the World Health Organisation articulated its third Global Patient Safety challenge of ‘medication without harm’ and aims to reduce severe avoidable medication related harm globally by 50% by 2020. Currently the estimated cost of managing definitely avoidable adverse drug reactions is £98.5 million per year and these errors are directly responsible for approximately 700 deaths annually. Reducing medication errors can clearly have a significant and immediate effect on patient safety.
Like me, every clinician has the potential of making a medication error and it is only by understanding the cause of medication errors that we can improve the processes to minimise the risk these occurring. The national Medicine Safety Programme (MSP) has been set up to work on reducing these errors and has three focus areas; high risk drugs, high risk processes, and patients with high risk vulnerabilities.
According to the 2018 report the most errors with potential to cause harm happen in primary care, as this is where most medication used in the NHS is prescribed and dispensed. The NHS long term plan indicates how useful pharmacists can be to improving medicines safety and this has already been proven in primary care. In 2012 the PRIMIS team found that the PINCER intervention was effective in reducing the range of clinically important and common medication errors in general practice, in combination with pharmacists undertaking patient reviews.
The quality improvement requirements in the new GP contract outline the expectations to improve prescribing safety in primary care, and the Academic Health Science Networks (AHSNs) are well placed to support this. During 2019-20 we are supporting the implementation of the PINCER intervention across England. This project supports multidisciplinary teams working in primary care to not only identify cases of hazardous prescribing, but also undertake root-cause analysis and quality improvement processes to reduce the likelihood of these errors re-occurring. This will ensure that medication errors are not only identified and corrected before harm occurs, but reduces that chance of the same error being repeated.
The health service still has a long way to go to removing avoidable errors but we are starting to see real change in this area. As a national project, PINCER collects anonymised data in one system and so far, the records of more than 10.7 million patients have been searched to identify instances of potentially hazardous prescribing. Over 500 pharmacists have undergone training to deliver the PINCER intervention and data has been uploaded from over 1,024 GP practices in England with more coming online every day.
Posted on September 16, 2019 by Joanna Garrett, Senior Project Manager, West of England AHSN