Using drugs safely
BMJ 2002; 324 doi: https://doi.org/10.1136/bmj.324.7343.930 (Published 20 April 2002) Cite this as: BMJ 2002;324:930All rapid responses
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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
Competing interests: No competing interests
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)
Competing interests: No competing interests