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Hunt urges greater transparency over medication errors


Hunt urges greater transparency over medication errors

A study has revealed an estimated 237 million medication errors occur in the NHS in England every year, and avoidable adverse drug reactions (ADRs) cause hundreds of deaths.

Researchers from the Universities of York, Manchester and Sheffield report that an estimated 712 deaths result from avoidable ADRs. They say, however, that ADRs could be a contributory factor to between 1,700 and 22,303 deaths a year.

The report, funded by the UK Department of Health Policy Research Programme, will be unveiled at the World Patient Safety Science and Technology Summit today. Health Secretary Jeremy Hunt is addressing the summit and is expected to outline steps the NHS is taking to reduce mistakes. These include the continued rollout of the much delayed electronic prescribing - only a third of hospitals have an effective system in place.

The Department of Health and Social Care believes the roll out of electronic prescribing systems across more hospitals could reduce errors by 50%. In his speech, Hunt will also say there needs to be greater openness about mistakes, so the NHS can learn from them.

Of the total estimated 237 million medication errors that occur, the researchers found that almost three in four are unlikely to result in harm to patients, but there is very little information on the harm that actually happens due to medication errors.

This led researchers to review studies related to the harm caused to patients from ADRs. As well as the number of deaths reported, they also showed that avoidable ADRs had significant cost implications, at £98.5 million per year, but this could be significantly higher.

The economic impact of medication errors varied widely, from £60 per error for inhaler medication, for example, to more than £6 million in litigation claims associated with anaesthetic errors.

The team is calling for more work to be done on finding cost-effective ways of preventing medication errors and their potential harm to patients.

The report, which reflects on 36 studies that details medication error rates in primary care, care homes and secondary care, showed that the most errors with potential to cause harm happen in primary care (71%), which is where most medicines in the NHS are prescribed and dispensed.

Errors were more likely to occur in older people and in patients with multiple conditions and using many medicines.

Professor of Health Economics at the University of York, Mark Sculpher, said: “Although these error rates may look high, there is no evidence suggesting they differ markedly from those in other high-income countries.

“Almost three in four errors would never harm patients and some may be picked up before they reach the patients, but more research is needed to understand just how many that is.”

Rachel Elliott, Professor of Health Economics from The University of Manchester said “The NHS is a world-leader in this area of research, and this is why we have a good idea about error rates. There is still a lot to do in finding cost-effective ways to prevent medication errors.

“What this report is showing us is that we need better linking of information across the NHS to help find more ways of preventing medication errors.”

Fiona Campbell, Research Fellow from the University of Sheffield’s School of Health and Related Research, said: “Measuring harm to patients from medication errors is difficult for several reasons, one being that harm can sometimes occur when medicines are used correctly, but now that we have more understanding of the number of errors that occur we have an opportunity to do more to improve NHS systems.”

Industry reaction

Duncan Rudkin, chief executive of the GPhC, said: “We welcome the new measures to help reduce medication errors and improve patient safety announced by the Secretary of State today. We know that pharmacy professionals play a key role in patient safety, including identifying and correcting errors as well as supporting patients to take their medication safely.

“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.  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 change in legislation in relation to dispensing errors highlighted by the Secretary of State is an important and welcome step to support a learning culture, as it will remove a barrier for those working in registered pharmacies to improved reporting and learning. We also look forward to the government’s consultation on removing the threat of criminal sanctions for dispensing errors made by pharmacists and pharmacy technicians working in settings other than registered pharmacies.”

Managing director of Numark, Jeremy Meader, commented: “Numark is a strong advocate of robust and appropriate technology to support in the accurate dispensing and supply of medicines and within our proposition, use and support of leading edge IT in enhancing further accuracy is very much in place.

"We are encouraged by Mr Hunt’s comments that a culture needs to be created to stop errors form happening and pharmacy is totally supportive of this. The process of de-criminalising dispensing errors will further enhance an open and transparent culture in pharmacy and we commend Mr Hunt in supporting this change. We will be seeking a further dialogue with Jeremy Hunt to continue to promote the vital role that community pharmacy plays."


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