86,085 medication incidents across the NHS in England and Wales were reported in 2007, up from 64,678 in 2006, says the National Patient Safety Agency (NPSA).
However, this indicates that the NHS has significantly improved its reporting culture and is willing to come forward when mistakes have been made, it adds.
The majority of incidents, reported by frontline NHS staff in acute, mental health and primary care sectors between January and December 2007, resulted in no or low harm to patients, says the study, which is entitled Safety in Doses. The most serious incidents were caused by medicine administration (41%), followed by prescribing (32%).
The NPSA’s Reporting and Learning Service (NRLS) received 100 reports of medication incidents of death and severe harm during 2007, 62% of which involved injectable medicines. Three incident types – unclear/wrong dose of frequency, wrong medicine and omitted/delayed medicines – accounted for 71% of the fatal and serious harms, the report shows, while the types of medicines most frequently associated with severe harm included cardiovascular, anti-infective, opioid, anticoagulant and antiplatelet medicines.
However, after previous guidance was issued by the NPSA around the safe use of potassium chloride injection and oral methotrexate, there were no further incidents of death or severe harm in 2007 involving these medicines.
The study’s findings were welcomed by the NHS’ medical director, Sir Bruce Keogh. “Patient safety is the highest priority for the NHS and the government. The vast majority of NHS patients experience good quality, safe and effective care and this is reflected in today’s figures which show that the majority of medication incidents, 96%, had clinical outcomes of low or no harm to patients,” he said.
However, Sir Bruce added that all NHS organisations are expected to examine the Agency’s recommendations carefully and, where necessary, take steps to implement them in order to ensure that the services they provide are as safe as possible. “We have learnt from industries such as aviation that scrupulous reporting and analysis of safety related incidents, particularly ‘near misses,’ provides an opportunity to reduce the risk of future incidents. Through the NPSA, the whole of the NHS can learn from the experiences of individual organizations,” he said.
“Millions of medicines are prescribed in the community and in hospitals across England and Wales each day – the majority of these are delivered correctly and do exactly what they are meant to do. However when an incident does occur, it is vital we learn from this to ensure patients are not harmed,” added the NPSA’s chief executive, Martin Fletcher.
