Fwd: Safety review shows increased reporting of adverse incidents with drugs in NHS
Prithi Nair
From: N S Mani <drnsm...@gmail.com>
Date: Fri, Sep 18, 2009 at 5:08 AM
Subject: Safety review shows increased reporting of adverse incidents with drugs in NHS
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Safety review shows increased reporting of adverse incidents with drugs in NHS
Susan Mayor
1 London
The number of reports of adverse incidents involving drugs has increased considerably, shows a review of drug incidents throughout the NHS in England and Wales published this week, which indicates that the reporting culture has improved.
The National Patient Safety Agency (NPSA) found a large increase in the reporting of drug incidents to the National Reporting and Learning Service (NRLS), a system for collecting reports of health system failures and errors in all NHS organisations, from 64 678 incidents reported in 2006 to 86 085 in 2007.
The report’s authors consider that the increase indicates that the NHS has improved its reporting culture and that health professionals are more willing to come forward when drug mistakes have been made.
"It is encouraging to find that there was a significant increase in the reporting of medication incidents to the NRLS," they said. "More reporting enables more learning and opportunities for improving patient safety, and should not be interpreted as an increase in the number of medication incidents that are actually occurring in the NHS."
However, they cautioned that there are still very few medication incidents being reported by primary care, mental health, and some acute care organisations.
Analysis of 72 482 medication incidents that occurred (rather than just being reported) during 2007 showed that most (96%) resulted in no harm or low harm to patients.
There were only 100 drug incident reports of death and severe harm to the NRLS. Most of these were caused by errors in drug administration (41%) and prescribing (32%).
Incidents involving injectable drugs accounted for nearly two thirds (62%) of all reported incidents leading to death or severe harm, similar to the number in the year before. The review’s authors noted that injectable drugs are often the most complex and potent, requiring complex calculations, methods of preparation and administration, and systems for monitoring.
Overall, incident reports involving unclear or wrong dose, frequency, or rate of administration were the commonest problems and caused the most deaths and severe harm. The review found that miscalculation, failure to titrate the dose to the patient’s needs; miscommunication between health professionals; and failure to check the drug dose before dispensing, preparing, or administering a dose were the most common factors that contributed to dosing errors.
The report says that NHS organisations should review the number and quality of drug incident reports received locally and identify whether current arrangements are enabling local learning and action to minimise the risk of harm to patients.
Bruce Keogh, NHS medical director, said, "The vast majority of NHS patients experience good quality, safe and effective care, and this is reflected in the figures, which show that the majority of medication incidents had clinical outcomes of low or no harm to patients.
"However, we expect all NHS organisations to examine the NPSA’s recommendations carefully and where necessary take steps to implement them in order to ensure that the services they provide are as safe as possible.
"We have learnt from industries, such as aviation, that scrupulous reporting and analysis of safety related incidents, particularly ‘near misses,’ provides an opportunity to reduce the risk of future incidents. Through the NPSA, the whole of the NHS can learn from the experiences of individual organisations."
Cite this as: BMJ 2009;339:b3613
Safety in Doses: Improving the use of Medicines in the NHS is at www.npsa.nhs.uk/nrls/medication-zone.
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Dr N S Mani
Associate Professor
Govt Medical College Thrissur 680596
+91 94460 88533
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Prithi Nair