The UK’s National Institute for Health and Clinical Excellence is collaborating with the National Patient Safety Agency on a pilot project aimed at generating guidance on cost-effective interventions to prevent or mitigate patient harm in the National Health Service.
The project, which runs from April to November 2007, will assess evidence on the clinical and cost effectiveness of two safety interventions: systems- and information technology-based interventions in medicines reconciliation; and the prevention of ventilator-associated pneumonia. Safety guidance on these topics is expected to be issued to the NHS in November.
The project springs from a review of patient safety commissioned by the UK’s Chief Medical Officer. The resulting recommendations in Safety first: a report for patients, clinicians and healthcare managers, published by the Department of Health in December 2006, “reaffirmed the place of patient safety at the heart of the healthcare agenda," NICE and the NPSA pointed out.
The aim of the medicines reconciliation review is to identify and evaluate the clinical and cost effectiveness evidence from published studies for medicines reconciliation processes at the point of admission to hospital. Medicines reconciliation is defined by the Institute of Healthcare Improvement as “the process of identifying the most accurate list of patient’s current medicines – including the name, dosage, frequency and route – and comparing them to the current list in use, recognising any discrepancies, and documenting any changes, thus resulting in a complete list of medications, accurately communicated”.
Absence of medicines reconciliation: longstanding issue
Medication errors can occur at a number of key transition points, including hospital admission, discharge and transfer from one specialty to another, notes NICE in its draft scope for the review. The absence of medicines reconciliation has been a longstanding problem that can result in medication errors and potential or actual harm to patients. According to NPSA data, there were a total of 7,070 reported incidents of medication errors involving hospital admission and discharge between November 2003 and March 2007, two of them resulting in death and 30 in severe harm to the patient.
The main institutional reason for the lack of medicines reconciliation has been a vacuum in ownership of the process, NICE explains. While historically junior doctors have been responsible for taking a clinical and drug history from patients on admission, problems still arise as patients or their families are not always aware of which medication they have been prescribed or the correct dose/route of administration, it notes.
“Patients often bring in their drugs out of the packaging or bring medication belonging to someone else,” NICE adds. “Older people with polypharmacy often have particular problems around the knowledge and understanding of what drugs they take and why. Often patients are asked about the medication they are taking, which then results in a failure to record ophthalmic, topical or over-the-counter medication.”
Antibiotic interventions for VAP?
The other systematic review will consider the clinical and cost effectiveness evidence for antibiotic interventions and oral decontamination (oral application of antibiotics or antiseptics) for the prevention of ventilator-associated pneumonia. The condition, which is as primary hazard in intensive care units and causes complications in 8%-28% of patients receiving mechanical ventilation, occurs when infection floods the small, air-filled sacs (alveoli) in the lung responsible for absorbing oxygen from the atmosphere.
VAP is distinguished from other forms of infectious pneumonia by the different types of micro-organisms responsible, the antibiotics used to treat the condition, the methods of diagnosis, ultimate prognosis and effective prevention measures, NICE observes. For critically ill and postoperative patients receiving mechanical ventilation, the condition is a significant cause of morbidity and mortality.
When VAP is first suspected, the bacterial source of the infection is typically not known and broad-spectrum antibiotics are given until the particular bacterium and its sensitivities are determined, the draft scope notes. The choice of initial therapy is entirely dependent on local knowledge, though, and successful treatment is “a difficult and complex undertaking”. Even with broad clinical experience of the disease, NICE comments, “no consensus has been reached concerning issues as basic as the optimal antimicrobial regimen or its duration."