Dipak Duggal, MR Pharms, MBA, Director of Medical Affairs, BD (Becton, Dickinson and Company)
A published research paper published in 2018 has highlighted the strikingly high incidence of medication errors in the NHS; researchers from the Universities of York, Manchester and Sheffield report that an estimated 712 deaths result from avoidable adverse drug reactions (ADR) every year. ADRs could, however, be a contributory factor to up to 22,303 deaths a year, they report.
In addition to the loss of human lives, the cost to the health system is enormous and estimated amount is around £1.6 billion per annum; this is a staggeringly high amount which leading commentators and the government have taken notice of, and then UK government recently announced new patient safety measures.
"Automation and e-prescribing are certainly ways to help reduce the incidence of medication errors"
Undoubtedly automation and e-prescribing are certainly ways to help reduce the incidence of this type of error.
Critical Stages: Prescribing, Dispensing, and Administration
I’ve been campaigning to bring the right level of attention to patient safety across a variety of adverse events, including medication errors. In fact, studies show that 18.7 - 56 per cent of all adverse events among hospitalized patients result from preventable medication errors.
Typically medication errors take place at the prescription, dispensing, and administration stages.
Several studies show that medication errors are particularly likely to be linked to IV infusion, not surprising given that 90per cent of hospital patients receive medication via the IV route, making this a key process to focus on for improvement. IV administration is also identified as a frequent contributor to medication errors and injuries that result from them.
Most MEs occur during the prescription and administration phase, but administration errors are also the hardest to intercept.
Dispensing stage errors are also frequent and under-reported, meaning their incidence could indeed be much higher than we think. The dispensing error rate detected in prospective observational studies is between 0.79per cent and 33.5per cent, while retrospective studies of incident reports suggest that the rate of dispensing errors was actually reported as being between 0.0147per cent and 0.13per cent. Typically these errors are due to human error such as confusing look-alikes/sound-a likes in medication, high pharmacy workloads, low staff numbers, staff inexperience, and rushing to complete tasks.
When it comes to preparation errors, in a recent UK study, incorrect product labelling was identified in 43per cent of doses, the wrong diluents was used in 1per cent of cases in UK, and at least one deviation from proper aseptic technique was observed among 100per cent of cases. In addition to this, 13per cent of preparations failed to meet the 10per cent acceptable tolerance threshold, and dose variations ranging from 64.9per cent to 94.2per cent were recorded.
Automated and solutions –such as e-prescription systems –can be applied to help reduce prescription errors primarily when these are caused by inaccuracies resulting from staff shortages and lack of time. Integrated with automation in the pharmacy and the ward proves instrumental at the dispensing stage, helping staff locate the right drug, in the correct dosage at the right time, promoting greater safety, but also general efficiency.
At the administration stage, increased automation of processes can also play a critical role helping reduce dose error reduction via closed-loop methods.
The Human Element
So while there are some specific processes that require particular attention, the overarching requirement is that of establishing a culture of patient safety. Specifically, although medicines management automation and e-prescribing are must-dos for hospitals, they cannot alone curb the issue sufficiently without work to change processes and culture simultaneously being undertaken.
The entire medication management process needs to be optimised, and while technology will play a critical, enabling role, the way this technology is implemented and used throughout the hospital setting is what will make the most significant impact. Training, but also informal activities such as ward-walks and interviews with nursing and pharmacy staff, play a critical role in supporting hospitals to manage risk alongside the implementation of automation and technology.
The implementation of a holistic patient safety culture and automation also critically enables the achievement of ‘The Five Rights of Medication Administration’ as set out by the Institute of Healthcare Improvement, which recommends that to reduce medication error and harm it is necessary to keep in mind the following: the right drug administered to the right patient, the right dose via the right route, and at the right time.
Another critical element is the promotion of unique identifier barcodes to ensure that the right drug reaches the right patient. Bar coding is useful far beyond merely the pharmacy setting and enables tracking and efficiency from dispensing right through to the patient’s bedside, such as when bar coding is also present on a wristband worn by the patient, for example.
On-going change management that combines new technical implementations and advances is a crucial feature of all the successful examples seen over the years, where hospitals and trusts have decided to tackle the issue of medication error by understanding which processes were lacking.
One key example is the STS AG Hospital in Thun, Switzerland, which recently became the first hospital in the world to introduce a fully automated hospital-wide prescription medicines supply chain for better delivery of patients’ medicines from the central pharmacy to the ward or care unit improving patient safety.
Traditionally, medication dispensing cabinets are manually filled and replenished with drugs by the hospital pharmacy. The new model provides secure storage of medicines on the ward and facilitates improved patient safety and efficiency in medication dispensing. Individual drugs are stored in separate drawers and pockets to avoid confusion, and if stock is low the system automatically sends a replenishment order to the hospital pharmacy.
It’s clear that engaging in innovation isn’t just about having an automation strategy and purchasing technology, although that is a positive step change, but also means understanding the potential benefits it can bring when combined with training and engaging staff, so they are enabled to ensure that the critical objective of patient safety is promoted in all processes and by every member of staff.