Around 1.1 billion prescriptions are supplied each year in primary care
, and every day a mid-sized hospital supplies around 50,000 doses to its patients
. As healthcare professionals, we don’t set out to make an error when delivering these medicines. But even in the safest healthcare system in the world, mistakes do occur, and far more frequently than I imagine anyone is comfortable with.
These incidents cause thousands of people harm, ranging from moderate to serious harm to death
. Meanwhile, avoidable adverse drug reactions cost the NHS around £98.5m per year
. Our understanding of the scale of the harm caused by medicine safety incidents is greater than ever before, so it’s time for the NHS to do more to prevent them.
Learning from the evidence
In February 2018, a comprehensive review of medication error-related harm estimated that 237 million errors occur every year in England, and that 68 million of these cause harm
While the harm may appear in one part of the health system, the cause (and most likely the solution) lies across the system
The report clearly showed that significant error and harm occurs during prescribing and supply in primary care, and during administration in care homes and hospitals. However, it is increasingly NHS Improvement’s view that while the harm may appear in one part of the health system, the cause (and most likely the solution) lies across the system; NHS Improvement and other central health bodies need to address this in their efforts to improve safety.
We can also learn from the National Reporting and Learning System about the kinds of medicines commonly involved in error; in a national review of reported medication-related harms, anticoagulants were, by some distance, the group of medicines most commonly associated with reported harm
. And back in 2004, non-steroidal anti-inflammatory drugs (NSAIDs) and diuretics were identified as the medicines most commonly involved in admissions to hospitals as a result of medicines harm
. The NSAID aspirin was the biggest culprit, and gastrointestinal bleeds were the most common adverse drug reaction.
When we are learning from medicines harm, it is also important to consider other sources of evidence, such as the patient. For instance, how can a three-day prescription for 50mg prednisolone to treat an eye problem have led to seven years of a high-dose corticosteroid for a patient who didn’t need it? Imagine the harm that was caused. And imagine the number of opportunities healthcare professionals and the patient had to ask: “Is this right?”
Tackling medication error-related harm
The World Health Organization (WHO) has challenged every health system to halve severe and avoidable harm caused by medicines by 2022
. Since the challenge was announced in 2018, NHS Improvement has been working to generate a list of national priorities and develop a programme approach to improving medicine safety. In January 2019, the importance of the medicines safety in the wider context of patient safety was confirmed in the ‘NHS Long-Term Plan’, which committed to “improve patient safety and reduce patient harm and the substantial costs associated with it through a new ten-year national strategy”, which will be published later in 2019; and to “design a new Medication Safety Improvement Programme”.
There are familiar issues appearing in the work we’ve done so far to design the programme: anticoagulants, care homes, and frail older people. Of course, errors occur in these areas, in part because it’s challenging to identify outcome measures that are sensitive enough to identify the consequences of our actions.
And that’s the nub of the matter. If it was easy, it would have been done already.
A major advantage of a national programme is that it enables different parts of the NHS and wider groups to work together in an effective manner
A major advantage of a national programme is that it enables different parts of the NHS and wider groups to work together in an effective manner. The medical directorate in NHS Improvement where I sit, and the organisation’s patient safety directorate, are working with colleagues in all parts of the NHS, including national organisations, providers and academic health science networks, as well as academia, national pharmacy organisations and patient groups. All have been enthusiastic and generous with their time in finding similarities and areas in which collaboration and coordination will boost capacity, focus and our potential to improve.
We have already published two tranches of medication safety metrics. These metrics reflect medicines that are more commonly associated with admission to hospital, and therefore form an important focus for the reduction in overall harm. Together with local quality improvement approaches, these metrics will improve patient care and allow us to measure our progress.
Empowering patients in the drive for safety
Despite these efforts, I am convinced that the single change that would make the most difference in reducing errors is allowing patients to become more involved in their own care by treating them as equal partners. This may be challenging for some of us, as healthcare professionals; we are used to being the ‘expert’ in these situations. But we must allow patients to become their own safety advocate; to understand what they are taking, how it should be taken and how it should feel, and to be confident enough to discuss their medicines with a healthcare professional.
Pharmacy teams will be at the heart of these patient conversations. The WHO has the simple phrase ‘Know. Check. Ask.’ to focus our thoughts, but we also recommend other resources for person-centred care, such as ‘Me and my medicines’ and ‘Choosing wisely’.
Rising to the challenge
We must think hard about how we prevent these errors and reduce harm. Technology, training and standardised procedures will all have their place, and the Medicines Safety Improvement Programme will provide focus and coordination for the range of activities being undertaken in medicines safety across the NHS.
We can improve patients’ and the public’s understanding of medicines, their benefits and risks; improve the packaging and labelling of medicines; continue to nurture a medicines safety culture; and support the wider safe use of technology to improve care for patients. Together, we can rise to the WHO’s challenge to provide a measurable reduction in harm.
Richard Cattell, deputy chief pharmaceutical officer, NHS Improvement
 NHS Business Services Authority. How we process prescriptions. Available at: https://www.nhsbsa.nhs.uk/pharmacies-gp-practices-and-appliance-contractors/payments-and-pricing/how-we-process-prescriptions (accessed February 2019)
 Policy Research Unit in Economic Evaluation of Health and Care Interventions, Elliott RA, Camacho E, Campbell F et al. Prevalence and economic burden of medication errors in the NHS in England. 22 February 2018. Available at: http://www.eepru.org.uk/wp-content/uploads/2018/02/eepru-report-medication-error-feb-2018.pdf (accessed February 2019)
 University of Sheffield. More than 200 million medication errors occur in NHS per year, say researchers. 23 February 2018. Available at: https://www.sheffield.ac.uk/news/nr/200-million-medication-errors-occur-nhs-every-year-1.765781 (accessed February 2019)
 Unpublished investigation of the incidents reported on the National Reporting and Learning System in 2017, by the NHS Improvement patient safety team
 World Health Organization. The third WHO Global Patient Safety Challenge: Medication Without Harm. 2018. Available at: https://www.who.int/patientsafety/medication-safety/en/ (accessed February 2019)
 NHS England. NHS Long-Term Plan. 7 January 2019. Available at: https://www.gov.uk/government/news/nhs-long-term-plan-launched (accessed February 2019)