Nearly one in 10 hospital prescriptions contains a mistake, ranging from the minor to the potentially lethal, according to research commissioned by the General Medical Council. However, very few errors would have caused serious harm. The research team, led by Professor Tim Dornan of the University of Manchester, examined the issue amid rising fears inexperienced doctors were making prescription errors which could, at worst, result in a patient dying.
The team examined 124,260 prescriptions across 19 hospitals - and found just under 9% contained errors. Of these 11,077 errors, overwhelmingly intercepted and corrected before reaching the patient, about 2% contained potentially lethal instructions - such as failing to take account of a patient's allergies. More than half involved errors in which a patient's medication was not prescribed and 40% were involved illegible or ambiguous prescriptions.
Very few of these mistakes caused actual harm to a patient because on the whole they were stopped by senior doctors, nurses - and in particular pharmacists. But the study did not find doctors fresh out of medical school were making the most mistakes - as has often been suggested,
"The research shows the complexity of the circumstances in which errors occur and argues against education as a single quick-fix solution”, said Professor Dornan. However, the GMC is calling for a UK-wide standard prescription chart as exists in Wales. Support for the idea is provided by Professor Peter Rubin (chairman of the GMC), Dr Hamish Meldrum (British Medical Association), and Joyce Robins (Co-Director of Patient Concern). A Department of Health spokesman said it would continue to look into the benefits of electronic prescribing system.
However, Professor Simon Maxwell, of the British Pharmacological Society said he was “dismayed at the suggestion that improved education and training is not a central part of the solution. There is plenty of evidence from around the world to show that when appropriate education and training are delivered, prescribing improves." Source: BBC, 3 December 2009. http://tinyurl.com/ydfbepb
Errors in the administration of injected medication occur frequently in intensive care units, a study of 113 units across 27 countries suggests. Over a 24-hour period, 441 patients out of 1,300 were subject to errors, and seven suffered permanent harm. Nearly half of the affected patients suffered more than one mistake. The most frequent errors related to the wrong time of administration and missing doses. Stress, tiredness, recent changes in the drug’s name, poor communication, and protocol violations were cited as contributing factors. Lead researcher Dr Andreas Valentin recommended error reporting systems and routine checks at shift changes. The Intensive Care Society said many units had developed patient safety training programmes, including measures to learn from ‘near misses’. Work was also under way to standardise concentrations of some drugs for critically ill patients, refine the use of antibiotics and minimise the risk of adverse drug reactions. Source: BBC, 13 March 2009. http://tinyurl.com/b9cqz6
