Dispensing defence one of Hunt’s ‘ground-breaking’ plans to end errors

Health secretary Jeremy Hunt has set out three “ground-breaking” measures to tackle 200 million medication errors across the NHS each year.
Mr Hunt – who set out the initiatives at the Annual World Patient Safety, Science and Technology Summit in London today (February 23) – said they will help to tackle the “appalling levels of harm and death that are totally preventable”.

One of these is the legal defence from criminal sanctions for pharmacists and staff who make an inadvertent dispensing error, which could become law as early as April.

This “will ensure the NHS learns from mistakes and builds a culture of openness and transparency”, the Department of Health and Social Care (DH) said today.

Another is a new system “linking prescribing data in primary care to hospital admissions”, which will help identify “if a prescription was the likely cause of a patient being admitted to hospital”, Mr Hunt said.

This will initially focus on how different medicines may be contributing to hospital admissions linked to gastrointestinal bleeding, and will be rolled out to “a broader range of medicines” following an evaluation in the spring.

Mr Hunt also plans to “accelerate the introduction of electronic prescribing systems” across “more NHS hospitals”, which “could reduce errors by up to 50%”, the DH said in a statement ahead of his speech.

237m medication errors a year
Mr Hunt’s announcement came in response to new research published today by the Universities of Sheffield, York and Manchester, which estimates that “237,396,371 medication errors occur at some point in the medication use process in England” per year. Prescribing errors and dispensing errors account for 21% and 16% respectively, while 54% were “administration errors”, the report’s authors said.

However, of the 237m errors, 72% have little or no potential for harm and “not all these errors would have reached the patient”, the authors stressed.

These medication errors account for 1,708 “definitely avoidable” deaths, according to the research.

The findings, based on 36 studies of “error rates in primary care, care homes and secondary care, and at the various stages of the medication pathway” are “at least 10 years old, so may not reflect current patient populations or practice”, the authors added.

Community pharmacy prevents errors
Responding to the research, National Pharmacy Association (NPA) chief pharmacist Leyla Hannbeck said patient safety is “deeply ingrained in the minds of community pharmacists, who dispense more than a billion prescription items each year”.

“It’s estimated that pharmacists query about 6.6m of those items, helping resolve many incidents that might otherwise have resulted in serious harm,” she added.

Janice Perkins, chair of the Community Pharmacy Patient Safety Group – which consists of representatives of all of the larger pharmacy chains, as well as the NPA – said the organisation is “committed to supporting healthcare leaders” implement Mr Hunt’s initiatives.

“Community pharmacists and their teams play a vital role in preventing medication errors, intervening on prescriptions and minimising risks to patients every day,” she said.

Greater access to patient records
“Discharge medication reviews taking place in community pharmacies, and community pharmacy read/write access to the GP patient record, would be significant enablers” to closer working between general practice and pharmacy teams, Ms Perkins said.

Royal Pharmaceutical Society (RPS) English pharmacy board chair Sandra Gidley also called for pharmacists to receive greater access to “vital information from a patient’s record, to enhance safety”.

“Pharmacists can and have been playing a vital role in reducing medication errors through transfer of patients between care settings,” she added. “We strongly believe that every care home should have a named pharmacist dedicated to improving medicine safety.”

C+D clinical editor Kristoffer Stewart appeared on BBC News this morning calling for pharmacy to have read/write access to patient records.

GPhC: We want to play our part
The General Pharmaceutical Council (GPhC) said it “strongly agrees” that “it is vital to have a learning culture across healthcare”.

“We will continue our work to promote a culture of openness, honesty and learning across pharmacy, and we will be urging everyone who employs pharmacy professionals or works within pharmacy to do the same,” chief executive Duncan Rudkin said.

Numark managing director Jeremy Meader said: “Pharmacy takes great pride in dispensing prescriptions accurately, as evidenced by the significantly low numbers of dispensing errors that occur.”

Mr Meader commended Mr Hunt’s support of the legal defence for dispensing errors, and said Numark “will be seeking further dialogue with Jeremy Hunt to continue to promote the vital role that community pharmacy plays”.

Source: C&D