How to avoid medication errors

A new study has highlighted the ongoing problem of medication errors in the NHS. Dr Pallavi Bradshaw, senior medicolegal adviser at Medical Protection, says that clinicians are only human – and help is at hand

A new study commissioned by the Department of Health and Social Care (DHSC) has highlighted the impact of medication errors across the NHS in England. While some of the figures make for stark reading – an estimated 700 annual deaths caused by such errors, at a cost of nearly £100 million – it is encouraging to see such open debate and action on the issue.

Medication errors account for a considerable number of complaints, claims and patient safety incidents and the government’s desire to tackle the issue is welcomed. At Medical Protection we have long provided advice, guidance and practical workshops to help members avoid such errors occurring.
In our experience, common causes of medication errors are:

• Wrong name
• Wrong drug
• Wrong dose
• Wrong frequency
• Wrong supply

When writing prescriptions, it is important to consider some fundamental points. Although they may seem obvious, in a busy clinical setting they are easily overlooked:
 

• Be sure that the treatment is indicated.
• Check that the intended drug is not contraindicated and that the patient does not have a history of adverse reactions to it.
• Ensure that it will not interact with the patient’s other medication and warn the patient about any potential interactions with over-the-counter medicines.
• Write legibly, taking special care if the drug name could easily be confused with another – use capital letters and give the generic rather than trade name.
• If you’re not sure which of two similar sounding drugs you should be prescribing, check with a senior colleague and confirm the correct spelling in the BNF.
• Write clear and unambiguous instructions for dosage, frequency and route of administration, avoiding abbreviations and leading decimal points (put a zero in front of it, eg, 0.2mg).
• Note the prescription and any other relevant information (eg, warnings given to the patient) in the medical record.
• Ensure that the patient is aware of what is being prescribed, and why.
• Use patient information leaflets to augment your verbal instructions, and be particularly careful to warn patients about possible side-effects, adverse drug interactions (including herbal medicines), or potentially dangerous activities, such as driving while taking drugs that induce drowsiness.

To err is human

Many errors are down to human error rather than a lack of knowledge; for example, accidentally prescribing the wrong medication, administering an incorrect dose, an oversight regarding allergies or a mix-up in patients. These unfortunate and unintended mistakes occur at various points in the process and involve different healthcare professionals.

The move to bring in new defences for pharmacists who make accidental medication errors, rather than prosecuting them for genuine mistakes, is a step in the right direction. But to bring about a real shift towards a culture of openness, learning and improvement from system-wide mistakes, these defences would need to be extended to doctors and other healthcare professionals. 

There has never been a more important time to debate this issue, and we are pleased work is underway.

Related content

Read our case study on a fatal medication error – and find out how Medical Protection helped

Resources

Our educational resources can provide help and support:

Online learning with PRISM
Workshop – Medication Errors and Safer Prescribing 
Workshop – Medication Errors and Safer Prescribing in Primary Care for your Team
Workshop – Prescription for Risk – A prescribing workshop for nurses