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MEDICATION ERRORS
Medication errors: reducing the harm
Errors can occur at any time in the process of prescribing, dispensing or administration by a range of different healthcare professionals and can cause considerable short term harm – or worse. KateWoodheadRGN,DMS and Chris Shawexplorewhy extra vigilance is required to ensure Trusts are notmaking simplemedication errors.
There is no particular universally agreed definition of medication error. Last year, The World Health Organization’s (WHO) latest Patient Safety Challenge was launched which aims to tackle medication-related harm.1
We
can expect challenges to our practices and systems before too long.
Their stated aim is to reduce the iatrogenic global burden of medication related harm by 50% within five years. A recent report from Sheffield’s School of Health and related Research (ScHARR) has revealed an estimated 237 million medication errors occur in the NHS in England every year and avoidable adverse drug reactions cause hundreds of deaths.2
The size of the problem
The use of medicines is very common and is also complex, sometimes involving as many as 30 different steps and almost as many people. Polypharmacy where many drugs are prescribed together to treat co-existing diseases in ageing patients, it is important that they do not interact. The problem exists in primary and
secondary care. Evidence suggests that the rate of prescribing errors in primary care is at least 11%.3
at least 7% of hospital admissions4
Adverse events account for and
one in 10 hospital in-patients experience a medication error,5
although only a few
result in significant harm to patients. Mahajan writing in the British Journal of Anaesthesia some years ago referred to
medication errors being among the top 10 causes of overall mortality worldwide.6
The
estimate of the number of errors cited is that there may be one drug error in every 133 anaesthetics. In intensive care practice, the incidence is reported to be around 130 errors per 1000 patient days.7
The WHO suggests that there are some classes of medications which are more liable to produce adverse reactions, those with a
Technological assistance may be developed in the form of apps to help to shape patients knowledge of medications, although it is recognised that this method of access will not be appropriate for everyone.
JUNE 2018
narrow therapeutic index tend to have more catastrophic outcomes if there is a small dosing error made. For example, the use of warfarin for anticoagulation is a high risk clinical situation involving a medication because it carries a high risk of bleeding if the international normalised ratio is too high and further risks of thrombosis if it is too low.8 The Clinical Excellence Commission of New South Wales has suggested high risk medications that can be summarised using an acronym A PINCH (anti-infective agents; potassium and other electrolytes; insulin; narcotics and other sedatives;
chemotherapeutic and immunosuppressive agents and heparin and anticoagulants.9
England’s new proposals
In advance of the report from WHO’s global challenge, the Department of Health set up a Short Life Working Group (SLWG) to review
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