UK - Improving medication safety in the NHS

Citation

(2007), "UK - Improving medication safety in the NHS", International Journal of Health Care Quality Assurance, Vol. 20 No. 7. https://doi.org/10.1108/ijhcqa.2007.06220gab.005

UK - Improving medication safety in the NHS

Keywords: Patient safety, Medical errors, Healthcare prevention

New recommendations to improve medication safety and reduce the number of medication errors in the NHS have been published by the National Patient Safety Agency (NPSA).

Medication is a vital component of healthcare – more than 900 million prescriptions are dispensed each year in the UK. While the vast majority of this treatment takes place safely and effectively, sometimes preventable harm to patients does occur.

The NPSA is publishing guidance on how to better manage five high risk issues that will help make the use of medicines safer. They are:

1. 1.

   anticoagulant medicines;

2. 2.

   liquid medicines administered via oral and other enteral routes;

3. 3.

   injectable medicines;

4. 4.

   epidural injections and infusions; and

5. 5.

   paediatric intravenous infusions.

In addition to these alert notices, the NPSA is issuing a range of practical tools and resources to support healthcare professionals and NHS organisations with implementation. This work forms the Safe Medication Practice Work Programme for 2007-2008, a joint initiative with the Department of Health and the Welsh Assembly Government.

Dr Keith Ridge said:

Whether at home or in hospital, medicines is an important part of patient care and managing medicines safely is a key objective for the NHS. In “Safety First” – the 2006 review of progress in making the NHS safer – the Chief Medical Officer, Professor Sir Liam Donaldson said patient safety must become the first priority for all healthcare professionals. This programme recognises the crucial role that all healthcare professionals, both clinical and non-clinical, have in delivering high quality, safe care to patients.

The NPSA aims to minimise risks by recommending:

• •

  medicine products with safer designs, for example ready-to-administer injectable medicines, and products with labelling and packaging that minimises the risk of selection errors;

• •

  medical devices with safer designs, for example the use of oral syringes to measure and administer oral liquid medicines;

• •

  safer storage of medicines in clinical areas, for example separating the storage of epidural and intravenous infusions; and

• •

  more involvement of patients, for example getting patients to share their blood clotting test information with their General Practitioner and Community Pharmacist when requesting a repeat prescription for oral anticoagulants.

Professor David Cousins, Head of Safer Medication Practice at the NPSA said:

Safe medication is everybody’s business in the NHS and small changes can make a real difference in reducing harm to patients. The NPSA has identified areas of risk with medicines usage and are making recommendations that will help to minimise these risks.

Recommendations include:

• •

  Actions that can make anticoagulant therapy safer – working with the British Society for Haematology, the NPSA is recommending a package of measures to reduce the risk of harm to the half a million patients in England and Wales who take these medicines every day to prevent blood clots. These measures include a redesign of the “yellow book” issued to patients prescribed anticoagulants, new guidelines on repeat prescriptions and wallet sized alert cards for patients.

• •

  Promoting safer measurement and administration of liquid medicines via oral and other enteral routes – safer practice recommendations on how to safely measure and administer these medicines.

• •

  Promoting safer use of injectable medicines – the NPSA has identified a number of latent system risks and is making recommendations to address them.

• •

  Safer practice with epidural injections and infusions – actions to reduce the risk of wrong route errors and minimize confusion between different types and strengths.

• •

  Paediatric intravenous infusions – highlighting the risk of creating low sodium levels in children by administering low sodium infusions during surgery or other treatments. Severely low levels can cause swelling of the brain that in rare cases can be fatal.