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Government takes steps to reduce annual burden of medication errors in England

BMJ 2018; 360 doi: https://doi.org/10.1136/bmj.k903 (Published 23 February 2018) Cite this as: BMJ 2018;360:k903
  1. Jacqui Wise
  1. London

Medication errors lead to an estimated 712 deaths in England every year and could be a contributory factor in 1700 to 22 303 deaths a year, concludes a report from the Universities of York, Manchester, and Sheffield.1

In response to the report the health and social care secretary, Jeremy Hunt, announced steps to improve patients’ safety. Speaking at the Global Patient Safety Summit in London on 23 February, he said, “Part of the change needs also to be cultural: moving from a blame culture to a learning culture, so doctors and nurses are supported to be open about mistakes rather than cover them up for fear of losing their job.”

The report, funded by the Department of Health and Social Care’s policy research programme, estimated that 237 million medication errors occurred in England each year. These could occur at any point, from prescribing and dispensing to administering and monitoring. The errors could range from delivering a prescription an hour late to a patient being given the wrong drug entirely.

The researchers classified 72% of the medication errors as minor, with little or no potential for clinical harm, 26% as having the potential to cause moderate harm, and 2% having potential to cause severe harm.

The report was based on 36 studies that analysed medication error rates in primary care, care homes, and secondary care. Most errors with potential to cause harm were in primary care (71%), where most drugs in the NHS are prescribed and dispensed. Errors were more likely to occur in medications for older people and patients with multiple conditions and using many drugs.

The researchers found little data on the economic burden of medication errors and had to use studies that measured harm from adverse drug reactions to estimate it. They estimated the cost to the NHS of definitely avoidable adverse drug reactions at £98.5m (€110m; $135m) a year, consuming 181 626 bed days, but said this might be much higher. The economic impact of medication errors varied widely, from £60 per error for inhaler medication, for example, to more than £6m in litigation claims associated with anaesthesia errors. The team called for more work to be done on finding cost effective ways of preventing medication errors and their potential harm to patients.

Rachel Elliott, professor of health economics at the University of Manchester, said, “What this report is showing us is that we need better linking of information across the NHS to help find more ways of preventing medication errors.”

Hunt announced new systems to link prescribing data in primary care to hospital admissions. These would initially focus on how prescribed drugs might be contributing to gastrointestinal bleeding. It would be possible to trace whether a patient who regularly took a non-steroidal anti-inflammatory drug ended up in hospital with gastrointestinal bleeding because they had not been given something to protect their digestive system. The first indicators will be published in the spring, and then the system would be broadened to cover more drugs.

In addition, Hunt announced new defences for pharmacists who made dispensing errors to build a culture of openness and transparency. The introduction of electronic prescribing systems in NHS hospitals would also be accelerated. Currently only a third of hospital trusts have a well functioning electronic prescribing system. Hunt also said that he would work with doctors, nurses, and pharmacists to find ways to reduce medication errors that resulted from poorly designed systems.

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