In an exclusive comment piece for HSJ, health secretary Jeremy Hunt announces an initiative that will aim to change culture as well as systems
We have lots of debates about different aspects of patient safety since Mid Staffs. But one we have not talked about enough is medication error – ironically, given that it affects one of the most common elements of patient care, namely the 147 prescriptions generated in primary care every second by the NHS. These are from a menu of 30,000 drugs and treatments, so the potential for error is huge.
It is testament to the professionalism of clinical staff that such errors are thankfully rare. But some studies suggest that up to 1 in 12 prescriptions – 8 per cent – may have a mistake in dosage level, course length or medication type. This reinforces earlier findings from General Medical Council-sponsored studies, which found prescribing error rates of between 5 and 9 per cent in general practice and hospital.
Most of the time these mistakes will be relatively harmless to patients, but the impact can be significant – between 5 and 8 per cent of hospital admissions are medication-related, amounting to 4 per cent of total NHS acute bed capacity.
‘Let’s speak up about the issue and have a constructive debate about the practical things that can be done’
The NHS is not unique in this: the World Health Organisation describes medication error as “a leading cause of injury and avoidable harm in healthcare systems across the world” and suggests that the cost associated with medication errors could run to $42bn (£33bn) annually. In response, it has launched Medication Without Harm, a global challenge to reduce severe avoidable medication related harm by 50 per cent over the next 5 years.
So what can we do about it here? Firstly, let’s speak up about the issue and have a constructive debate about the practical things that can be done. The catastrophic errors that led to the death of Wayne Jowett in 2001 – where a powerful anti-cancer drug was wrongly injected into his spine rather than a vein – led to changes in equipment design. But should it really have taken a tragedy of this scale to precipitate change?
By giving this issue more profile now, we can do much more to create a proactive, safety centred culture around medication, rather than simply slamming stable doors shut after horses have bolted. This must mean designing safety in, recognising the increasing complexity of care for a population that is ageing and living with different health conditions, and working closely with patients to ensure they are able to use medicines effectively.
So in the next few months I plan to launch an initiative focused on reducing prescribing and medication errors with Dr Keith Ridge, chief pharmaceutical officer at NHS England.
This will look at a number of areas where we can do better: from improving how we use technology such as electronic prescribing, to understanding how best to educate and inform patients about their medicines, as well as supporting seven-day clinical pharmacy services in acute hospitals and working with care homes and GPs.
It will also look at how we might improve the transfer of information about medicines when patients move between care settings, as we know that these transition points can be times when things go wrong.
When it comes to improving patient safety, the pattern for success is remarkably similar – you highlight the problem, collect data openly and transparently, develop practical models and good practice locally, and then embark on the journey to encourage people to make improvements team by team.
More than anything else you need strong clinical leadership, coupled with an infectious enthusiasm to challenge and find new ways of designing out error.
Hopefully, we can deliver that with this new initiative – and build on some of the excellent work already happening in parts of the NHS.