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EDITORIALS: Simon Maxwell, Tom Walley, and Robin E Ferner Using drugs safely BMJ 2002; 324: 930-931 [Full text]

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memory games miss the point

Adrian K Midgley   (21 April 2002)

A spoonful of sugar and a pinch of salt

Martin LeatherBarrow   (24 April 2002)

memory games miss the point 21 April 2002
Adrian K Midgley, GP, sabbatical on internetworking and health Exete EX1 2QS Send response to journal: Re: memory games miss the point	This is very disappointing. A group of medical educationalists conclude that the answer is in medical education. They make no mention of improving the system of prescribing so as to reduce the risks and error rate, instead perpetuating the idea that prescribing correctly is a game to be played with the memory. I prefer the views of the Leapfrog Group, established by safety- conscious firms to safeguard their employees when they receive medical treatment. In the UK most prescribing errors occur on handwritten prescriptions. Solution: don't handwrite them, use automation to improve legibility and chance of correctness. This is a quote from the first principle that Leapfrog impose upon hsopitals they are considering sending patients to:- "Computer Physician Order Entry (CPOE) Prescriptions in hospitals should be computerized. With computerized prescription systems, doctors enter orders into a computer rather than writing them down on paper, and the prescription can be automatically checked against the patient's current information for potential mistakes or problems. For example, before the doctor can complete the prescription order, the computer would check to see if the new prescription would interact badly with another drug the patient is taking, or if the patient has a known allergy to it. This type of system also reduces mistakes that occur from misreading a doctor's handwriting. Studies show a computerized prescription system can reduce serious medication mistakes by up to 86 percent." http://www.leapfroggroup.org/consumer_intro2.htm For more details follow http://www.leapfroggroup.org/FactSheets/CPOE_FactSheet.pdf
A spoonful of sugar and a pinch of salt 24 April 2002
Martin LeatherBarrow, Research Associate Department of Public Health & Epidemiology, The Medical School, University of Birmingham, England Send response to journal: Re: A spoonful of sugar and a pinch of salt	Editor - The recent report by the Audit Commission entitled A Spoonful of Sugar was indeed grim reading, and must be taken with a pinch of salt. The report suggested that nearly 1,100 people died last year in England and Wales as a result of medication errors or adverse reactions to medicines and that the number had increased fivefold in just 10 years. However, from previous research undertaken in this area, I would have expected it to be much higher. In contrast, Maxwell et al, specify that this alarming increase may be an overestimate inflated by changes in defining and reporting causes of death and cannot all be attributed to a true deterioration in prescribing. As they also note, studies elsewhere also hint at high rates, although the definitions and data have been questioned. Several studies and reports of late would appear to confirm that this is indeed the case, however, I contend that there remain serious and ambiguous considerations to be resolved. For according to the literature, serious adverse drug reactions are more frequent than generally recognised, and may actually be one of the leading causes of death in several countries. The report acknowledges that whilst much of the academic literature on the subject matter comes from overseas (mainly the USA), it now accepts that these findings can be transferred to the National Health Service. If this is the case, then some studies such as Lazarous et al (1998), make for very grim reading. For they have indicated that adverse drug reactions (ADRs) may be as high as the fourth leading cause of death in the United States. They estimated that in 1994 there were around 106,000 fatal ADRs in hospitalised patients in the US. It is also worth noting that their studies excluded medication errors (or adverse events) and concentrated on adverse drug events. They conclude that they had a different objective, to show that there are still a large number of serious ADRs, even when drugs are properly prescribed and administered. Lazarous et al, had also been quoted in the Globe and Mail (Toronto) as saying that the results could be extrapolated to Canada "with little danger" and that about 10,000 deaths occur in Canada each year as a result of adverse drug reactions. Obliviously alarmed at the report, Bains and Hunter (1999) conducted their own research to see if there really was an epidemic of deaths in Canadian hospitals arising from adverse drug reactions. Their estimates are that approximately 1824 deaths annually could be attributed to adverse drug reactions in Canada. This it should be noted, is substantially lower than the estimate of 10,000 deaths per year cited in the Globe and Mail (Toronto). It would nevertheless, rank as the 19th leading cause of death. However, in a rejoinder to Bains and Hunter, a further analysis of the data by Lexchin (1999), arrives at approximately 2925 deaths in Canada, attributed to ADRs. By the same token the statistics are also higher than that reported in the Audit Commission’s report of approximately 1100. Thus, with a population double that of Canada’s we should indeed be alarmed. So one must ask, who has got it correct. Perhaps the figures lie somewhere in the middle! Most of us are aware that all drugs carry the risk of potential side effects. However, the phrase 'medical harm' does seem rather paradoxical, in that it defies our expectations about medicine. The expectations that medicine will actually benefit, rather than actually harm us, and that individuals and institutional providers will improve rather than diminish our health. As Maxwell et al mention, the Audit Commission failed to distinguish clearly between medication errors, inevitable adverse reactions, and potentially preventable adverse reactions. This problem is also compounded by frequent use in the literature of definitions such as: inadvertent error, rebound effects, adverse medical events, serious adverse effects, iatrogenic harm, serious rebound phenomena, comiogenic harm, etc, etc, etc, to cover the same basic areas pertaining to harm to patients caused by pharmaceutical drugs. The true extent of adverse drug reactions (and fatalities) is unknown because of inadequate definitions, possible cover-ups, under reporting, a culture of blame, avoidance of responsibility, lack of training, inadequate computerisation systems, etc. For there are as many problems and concerns noted in the editorial, the report and elsewhere, as there are missing. Therefore, whatever the cause and precise frequency (and this needs to be addressed), clinical iatrogenesis pertaining to pharmaceutical drugs in primary and secondary care is extremely problematic. It does leads to great personal misery and injury, a diminished public confidence, hence, creating a mistrust of public institutions (as noted in the Reith Lectures, 2002), are expensive (including litigation) and wasteful for the National Health Service. Without question, it is now time to take onboard the Audit Commissions report (with the necessary changes), and this should include an independent academic multi-disciplinary commission (yes another commission), to supplement the current advisory panels. With the increased funding in last week’s budget for the NHS, this should be one of the most fundamental issues of concern facing the current Government, the National Health Service and related areas, plus of course the public. References _____________________________________________________________________ Abraham C, Taylor P. Drug reactions kill thousands: researchers. Globe and Mail (Toronto) 1998 (April 15th) Bains N, Hunter D. Adverse reporting on adverse reactions. eCanadian Medical Association Journal. 1999; 160: 350-351 (February 9th) Bates DW. Editorial: How worried should we be? Journal American Medical Association. 1998;279:1216-1217 (April 15th) Clinical: US data suggest adverse drug reaction could be a leading cause of death. The Pharmaceutical Journal. 1998; 260:582 Lazarous J, Pomeranz BH, Corey PN. Incidence of adverse drug reactions in hospitalised patients: a meta-analysis of perspective studies. Journal of the American Medical Association. 1998; 279 (15): 1200 -5. Lexchin J. eLetter: Rethinking the numbers on adverse drug reactions. eCMAJ 1999;160:1432 Science News Update. Week of April 15, 1998 Sylvester, R (2002) Philosopher to fight culture of mistrust. [The BBC Reith Lectures 2002] The Daily Telegraph (March 30th) Wilson RM, Runciman WB, Gibberd RW, Harrison BT, Newby L, Hamilton JD. The Quality in Australian Health Care Study. Medical Journal Australia.1995; 163 (9): 458-71 (November 6th)