The precise number of medication errors taking place in national health service hospitals is not known.
Comprehensive information concerning the number of patient safety incidents reported via the National Patient Safety Agency's National Reporting and Learning System was published in Patient Safety Observatory Report “Safety In Doses” in July 2007.
The report reviewed 60,000 medication incidents reported across the NHS between January 2005 to June 2006.
Information from this report concerning incidents from accident and emergency departments and acute hospitals is shown in tables 1 and 2.
Stage of medication process Incidents Administration/supply of a medicine from a clinical area 1,278 Monitoring/follow-up of medicine use 100 Preparation of medicines in all locations/dispensing in a pharmacy 160 Prescribing 342 Other 56 Total 1,936
Stage of medication process Incidents Administration/supply of a medicine from a clinical area 27,505 Monitoring/follow-up of medicine use 1,896 Preparation of medicines in all locations/dispensing in a pharmacy 7,339 Prescribing 7,491 Other 886 Total 45,117
The precise number of patients harmed by medication errors in hospital each year is not known.
However, the National Patient Safety Agency’s national reporting and learning system (NRLS) receives reports of patient safety incidents of actual harm involving medicines.
All national health service hospital trusts in England and Wales were connected to the NRLS by January 2005. Since this date, the number of medication incident reports has increased as NHS reporting culture and methods have improved. Increasing numbers should not be interpreted as increasing numbers of incidents but rather an increase in the number of incidents that are reported.
Number of NRLS reports involving medicines where harm has been reported April 2004 to March 2005 1,106 April 2005 to March 2006 6,001 April 2006 to March 2007 9,702 April 2007 to November 2007 6,544 Total 23,338
The following table provides information about reports to the national reporting and learning system (NRLS) about patients involving medicines.
Number of fatal NRLS reports involving medicines April 2004 to March 2005 12 April 2005 to March 2006 5 April 2006 to March 2007 27 April 2007 to November 2007 24 Date not available 17 Total 78
The National Patient Safety Agency (NPSA) has issued a number of safer practice recommendations to the national health service during 2007 concerning high risk medicines and practices. The topics selected are informed or triggered by reports to the national reporting and learning system by the NHS.
Patient Safety Alerts
Safer practice with anticoagulants
Promoting safer measurement and administration of liquid medicines via oral and other enteral routes
Safer use of injectable medicines
Safer use of epidural injections and infusions
Reducing the risk of hyponatraemia with intravenous infusions in children
These were issued on 28 March 2007.
Rapid Response Reports
In addition to these alerts, the NPSA issued three rapid response reports on medication topics between June and September 2007 to alert the NHS to medication risks and actions to minimise them. These included:
risk of confusion between cytarabine and liposomal cytarabine;
risk of confusion between non-lipid and lipid formulations of injectable amphotericin; and
fire hazard with paraffin-based skin products on dressings and clothing.
Design for Safety Information
The NPSA has also issued design for safety booklets on a number of medication topics to promote safe design with pharmaceutical manufacturers, and dispensaries in both primary and secondary care.
Patient Safety Guidance From NICE and the NPSA
On 12 December 2007, the National Institute for Health and Clinical Excellence and the NPSA issued patient safety guidance on medicines reconciliation when patients are admitted to hospitals.
Implementation
The NPSA is working with the local organisations, the Healthcare Commission, and Healthcare Purchasers to ensure that these safe practice recommendations are implemented. Health care organisations are also recommended to produce a medicine management report annually to describe local risks with medicines and how these risks are being managed.
Estimates of the rates of medication errors in hospitals at each stage of the medication process have been made from published United Kingdom research. The results are not directly comparable and depend on the definition of medication error used in respective studies.
For example, most studies on medication errors during administration exclude the administration of injectable medicines and find an error rate of between 5-10 per cent. Where research have examined administration errors with injectable medicines, error rates of up to 49 per cent. have been reported.
Stage of medication process Estimates of rate of medication error (Percentage) Prescribing 1-11 Dispensing 1-2 Administration (and where appropriate preparation) 3.5-49 Monitoring 1— 1 No overall estimate.
Not all medication errors have caused or have the potential to cause harm. Those that are associated with harm are called adverse drug events.