MEDICATION ERRORS


subside and nor will the need for cost savings,” he warned. “Trusts and policy makers are looking at new ways of working by turning to new technology in order to create a system that can cope efficiently with these pressures.” The new report, authored by a leading independent pharmaceutical expert ‘SAFE – Banishing Medication Errors in Secondary Care’15


, found that within hospitals the implementation of automation medication administration systems alongside ePMA systems would dramatically reduce the risk of medication errors. By putting the two systems in place together, thereby ‘closing the loop’, Trusts will be able to strengthen patient safety from the moment the drug is prescribed to when it is administered to the patient. “Over three quarters (79%) of medication errors within secondary care16


happen during


the administration process – so it’s vital that Trusts put systems in place to safeguard against this,” Paul noted. “We all know that errors are exacerbated by the increasing volume of work, staff shortages and the sheer rising number of patients accessing these health services. So, if we are going to accept that this situation is not going to change in the near future, then we need to offer a safety net for valued and indispensable healthcare professionals working on the frontline of patient care. “Introducing electronic prescribing and medicines administrations (ePMA) systems in hospitals is a priority and has the potential to halve the risk of medication errors – but as of November 2017, just 35% of acute Trusts (where more than 80% of inpatients’ prescriptions are written digitally), and less than 12% of mental health organisations had introduced the necessary systems.17 “When using ePMA systems as a standalone process, patient safety is improved to a certain degree. But technology also needs to protect against the nurse picking the wrong drug or dose or out of date stock from the drugs cupboard – ePMA as a standalone system won’t do this. “As such, a system to close the loop is also needed to ensure automated dispensing, electronic confirmation of patient identity and medication administration records. This will


EPR returns administration to Omnicell


EPR sends order to cabinet


The benefits we have seen since automation, coupled with the decision tomove from a model of three pharmacy departments to one single dispensing hub,


have been significant. Ewan Maule, Northumberland Tyne and Wear NHS Foundation Trust.


allow Trusts to track everything back to the patient from the moment the medication is prescribed to when it is administered to the patient.”


Omnicell has worked with Trusts, nurses and pharmacists who have embraced new technology and improved their patient’s safety and experience. The Department of Health report raised awareness of the scale of medication errors across the NHS and highlighted the need for technology, which is already available, to help solve this issue. “There is no excuse for poor medicines management within the NHS and we aim to continue sharing best practice and learning through medication-based automation,” Paul stated. “This includes demonstrating the efficiencies that ward based technology can provide to healthcare professionals managing medication, ensuring quality care remains at the forefront of our NHS. “As a healthcare community we have some way to go in recognising the impact of medication errors. A call for greater transparency and a culture that learns from mistakes has been heard, with new legislation decriminalising genuine medication errors made by pharmacists. However, technology in medicines administration is likely to play the biggest part in reducing medication errors in secondary care – from prescribing the drug to


Dr prescribes drug


administering to the patient. Transformational change, even in the most challenging of circumstances is possible to help deliver a world class health system.”


A family’s perspective


In January 2014, Philippa Gillespie, who had been a partner to Roy for over 30 years, and a mother of two boys, was admitted to hospital for an abdominal x-ray to determine if she had any additional health problems after suffering from severe constipation. The hospital housed detailed medical notes on Philippa as she had been living with lung cancer for the past year. At every outpatient appointment Philippa and Roy would make the hospital aware that she was allergic to penicillin both verbally and in writing. At the time she was admitted for the x-ray Philippa told six separate healthcare professionals about her allergy. Despite this, one of those six healthcare professionals administered a lethal treatment containing the drug to Philippa in error. Her condition deteriorated rapidly and she suffered a cardiac arrest – Philippa never regained consciousness and she died 3 days later. Her partner Roy commented: “I know mistakes are possible and are made, especially when staff are working under pressure. As a patient Philippa did absolutely everything she could to ensure the hospital staff were fully aware of her allergy. She probably did a lot more than most patients would do because she knew that accidents can happen. If this lethal mistake happened to someone as careful as Philippa it could happen to anyone. “That’s why it is vital that a system for dispensing and administering drugs should be able to eliminate basic human error.” Roy continued “With [an automated medication system] the errors are not as likely to occur as the nurse would have to override the warning. When systems like this are put in place it’s important that medical staff still combine the use of such systems with their own personal awareness. “I wouldn’t want anyone to go through what my family has been through. If something can be put in place to reduce the risk of this happening to anyone else, then it has to be supported. I think every hospital ought to be looking at anything that would improve the efficiency and safety of the system of administering medication to patients.” Roy believes this happened to Philippa because of the pressure that staff at the hospital were under. “The impact on the family as a victim of a mistake is enormous – of having someone snatched away from you needlessly is appalling,” he added. “We did not have time to say goodbye.


Nurse picks drug against order


Nurse administers meds Nurse scan drug removal 24 I WWW.CLINICALSERVICESJOURNAL.COM


“What made it worse for the boys and me was that we believed Philippa was in a place of safety. When I gave her a kiss, left her and walked back from the hospital that first night she was admitted, I was almost happy as I thought at least tonight she’s going to be okay. In a way it’s like being betrayed.”


JUNE 2018


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