Medication incidents must be reduced

Poor communication, documentation and handover processes, along with workload pressures, are some of the problem areas which must be addressed.

The National Patient Safety Agency (NPSA) estimates that preventable harm from medicines could cost more than £750 million each year in England. Learning from mistakes, with a view to implementing safer systems and processes is crucial, therefore, if the NHS is to reduce incidents of serious harm and associated costs in the future. Evidence from the NPSA that reporting culture has improved suggests that the NHS is building the foundations to assist learning from medication errors and is more willing to come forward when mistakes have been made – the number of errors reported increased from 64,678 in 2006 to 86,085 in 2007. Detailed analysis of 72,482 medication incidents has now enabled the NPSA to identify risks and areas for action, which it has now published in its report: Safety in doses.1 The report showed that although 96% of incidents resulted in low or no harm, 37 patients died during 2007, and another 63 suffered severe harm, with 62% of such cases involving injectable medicines. A further 2,710 also experienced moderate harm. The medication incidents were reported to the NPSA by frontline NHS staff in acute, mental health and primary care sectors between January and December 2007. Acute care (all specialties) remains the highest reporter of all incidents (73%) and medication incidents (76%). The most serious incidents were caused by errors in medicine administration (41%) and, to a lesser extent, prescribing (32%). Incidents involving injectable medicines represent 62% of all reported incidents leading to death or severe harm. Three incident types – unclear/wrong dose or frequency, wrong medicine and omitted/delayed medicines – account for the majority of fatal and serious harms from medication incidents (71%). The types of medicines most frequently associated with severe harm include cardiovascular, anti-infective, opioid, anticoagulant and anti-platelet medicines. However, following earlier guidance on the safe use of potassium chloride injection and oral methotrexate, there were no incident reports of death or severe harm in 2007 involving these medicines.

Reasons for errors