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Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis

BMJ 2019; 366 doi: https://doi.org/10.1136/bmj.l4185 (Published 17 July 2019) Cite this as: BMJ 2019;366:l4185

Linked editorial

Preventable harm: getting the measure right

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Pro-active Prevention and Amelioration Re: Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis

The excellent paper by Panagioti et al. [1] reminds us of the significance impact of preventable iatrogenic harm, affecting around 6% of patients. More than half the harm is due to mismanagement of prescribed medicines and other therapeutic management incidents. Further research is unlikely to substantially alter this estimate [2], and these findings should catalyze change in practice, policy and the prevailing zeitgeist.

In 2017, the WHO’s 3rd Patient Safety Challenge ‘Medication Without Harm’ called for action to strengthen monitoring systems, facilitate improvements in monitoring practices, and reduce medicines-related harm by 50% by 2022.[3, 4]. Unfortunately, little has changed. The previous WHO Global Patient Safety Challenge was effectively met by a checklist approach [5]. There are, of course, many arenas in which action is needed. Our own work in the area of residential care and older people seeks to build a consensus around a similar communications approach to enhance the systems and practices of medication optimisation. Relatively little work on iatrogenic harm has been undertaken in primary care or with older adults [1], but our work suggests that only pro-active checks by nurses or carers to identify and ameliorate adverse side effects can ensure that people in care homes are not sedated by antipsychotics or anxiolytics or kept awake by risperidone given at bedtime or confused by anti-muscarinics or left in pain [6, 7]. Comprehensive patient monitoring by nurses, juxtaposed with medicines charts, addresses this preventable, low-level iatrogenic harm, previously undetected or attributed to ‘age’ or ‘illness’, but which, if not addressed, can escalate to serious adverse drug reactions [8].

Panagiota and colleagues’ meta-analysis [1] may be the stimulus needed for healthcare systems to empower professionals to devote sufficient time and learning to person-centred monitoring and checking for potential adverse side effects, however mundane [9].

1. Panagioti Maria, Khan Kanza, Keers Richard N, Abuzour Aseel, Phipps Denham, Kontopantelis Evangelos et al. Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis BMJ 2019; 366 :l4185
2. Abbasi Kamran. First do no harm: the impossible oath BMJ 2019; 366 :l4734
3. WHO 2017 WHO launches global effort to halve medication-related errors in 5 years. Geneva/ Bonn. Available from: http://www.who.int/mediacentre/news/releases/2017/medication-related-err... (accessed 20 August 2017).
4. WHO. Medication without harm 2017. Available from: http://apps.who.int/iris/bitstream/10665/255263/1/WHO-HIS-SDS-2017.6-eng... (accessed 20 August 2017).
5. de Vries EN, Ramrattan MA, Smorenburg SM, et al. The incidence and nature of in-hospital adverse events: a systematic review. Qual Saf Health Care 2008;17:216-23. doi: 10.1136/qshc.2007.023622 [published Online First: 2008/06/04]
6. Jordan S, Gabe-Walters ME, Watkins A, et al. Nurse-Led Medicines' Monitoring for Patients with Dementia in Care Homes: A Pragmatic Cohort Stepped Wedge Cluster Randomised Trial. PLoS One 2015;10:e0140203. doi: 10.1371/journal.pone.0140203 [published Online First: 2015/10/16]
7. ADRE – THE ADVERSE DRUG REACTION PROFILE: HELPING TO MONITOR MEDICINES http://www.swansea.ac.uk/adre/ (accessed 17 July 2019)
8. Jones R, Moyle C, Jordan S. Nurse-led medicines monitoring: a study examining the effects of the West Wales Adverse Drug Reaction Profile. Nurs Stand 2016;31:42-53. doi: 10.7748/ns.2016.e10447 [published Online First: 2016/12/03]
9. Jordan S, Logan PA, Panes G, Vaismoradi M, Hughes D. Adverse Drug Reactions, Power, Harm Reduction, Regulation and the ADRe Profiles. Pharmacy (Basel). 2018 Sep 18;6(3). pii: E102. doi: 10.3390/pharmacy6030102. PubMed PMID: 30231573. http://www.mdpi.com/2226-4787/6/3/102/pdf

Competing interests: No competing interests

21 July 2019
Sue Jordan
professor of health services research
David Hughes, professor in health policy, Darren J. Edwards, senior lecturer in health psychology, Mojtaba Vaismoradi, professor of nursing,
Swansea University
Department of Nursing, Swansea University, Swansea SA2 8PP, UK