MEDICATION ERRORS Medicines
In May 2007, one of the key global patient safety solutions was reducing the number of look-alike, sound-alike medication names which were contributing to medication error. Many drug names look or sound like other drug names.
In addition to the names, other aspects which contribute to medication confusion are illegible handwriting, incomplete knowledge of drug names, newly available products, similar packaging or labelling, similar clinical use, similar strengths, dosage forms, frequency of administration and the failure of manufacturers and regulatory authorities to recognise the potential for error.12
A number of suggestions
were made to increase the safety of use with look-alike, sound-alike drugs such as the use of pre-printed orders or electronic prescribing. It was also muted that prescriptions included both the brand name and the non-proprietary name, dosage form, strength, directions and the indications for use.
Pharmacy computerised dispensing systems are suggested to increase safety by SWLG report. Collaborative working with the pharmaceutical industry is also suggested to reduce frequent changes of packaging by manufacturers. Research on look-alike, sound-alike drugs is still developing so the SWLG identify that a range of other initiatives should be considered, including making patients and professionals more aware of the errors, developing more robust checking systems and the use of bar code scanning to try to reduce incorrect selection.
Systems of practice
Hospital E-Prescribing and Medicines Administration ( HePMA) has been shown to significantly reduce medication errors and, while this is demonstrated in the literature, few NHS Trusts – approximately 35% – have rolled out the systems. They are very complex and there is a great deal of work and change to working practices required by pharmacy, medicine and nursing following implementation of the system. The changes need up to two years to successfully implement. In respect of clinical evidence and cost effectiveness the SWLG recommend that the roll out of HePMA must be accelerated, albeit with additional support to ensure successful implementation. Primary care systems for optimisation of medications have been incorporated into national guidelines, by both NICE and NHS England.
A dashboard is being produced by NHS Digital which will assist transparency and measurement. The indicators will be published to reduce error and promote safer prescribing. There will also be a development by the NHS Specialist Pharmacy Service to build an online repository of good practice examples and early action areas. The initial resource will be available later this year.
JUNE 2018
Closed loop technology in secondary care
Medication errors are a global problem and it was the World Health Organization (WHO) calling for medication errors to be cut by 50% in the next five years13
that prompted
the Department of Health to commission its own research into the size and scale of medication errors.
The estimated costs to the NHS of avoidable adverse drug reactions is £98.5 million per year, consuming 181,626 bed days, causing 712 deaths and contributing to 1,078 deaths. Adverse drug events in England have previously been estimated to be responsible for 850,000 inpatient episodes and costing £2 billion in additional bed days.14 Paul O’Hanlon, managing director, Omnicell UK & Ireland, is a pharmacist by profession and an expert in medication and supply management solutions to the global healthcare market. The company specialises
in improving patient safety from hospital to home. Paul believes that closed loop technology in secondary care is pivotal in tackling medication errors and improving patient safety from hospital to home. “The real tragedy behind these figures is the patients, families and relatives of loved ones affected by these unavoidable mistakes,” asserted Paul. “That’s why this spring, Omnicell is launching a ‘SAFE – Banishing Medication Errors in Secondary Care’ campaign targeting medical professionals, NHS organisations and key opinion leaders in an effort to raise awareness and drive real change in improving patient safety.” Although the Health Secretary has thrown light on this serious issue, Paul believes there still hasn’t been enough acknowledgment of how investment in the right technology could prevent these errors from happening. “The increasing demand on the NHS, especially during the winter period, will not
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