Assistant Director of Casework
The World Health Organisation's third World Patient Safety Day took place on 17 September. This year’s theme was medication safety. Since the start of my career in the mid-90s, patient safety has been a focus of my work. As a clinician, keeping patients safe from harm was at the core of my daily practice.
Later, I worked investigating maternal deaths, looking at what we could learn to keep future patients safe. Medication safety has always been a theme, as a clinician checking and preparing drugs and as a patient safety specialist developing guidance for healthcare professionals to safely administer medicines.
The impact of medication errors
Globally, medication errors and poor medication practice are some of the leading causes of avoidable patient harm. Prescribing errors and human factors like stress and high workloads are often at the root of mistakes. For example, drugs packaged in almost identical boxes and vials can be confused by clinicians, particularly in fast-paced emergency situations.
Here at PHSO we see medication errors in some of the cases we investigate. One example saw the complainant given double the prescribed dose of medication by a pharmacy.
The error went unnoticed for some time because the description on the packet quoted the correct dose, but the medication inside was incorrect. In response to our findings, the pharmacy implemented service improvements and the patient was awarded a financial remedy of £250.
Examples of poor practice
Some other examples of poor practice are:
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Polypharmacy (the use of multiple medications at the same time)
This is often seen in older people and patients with several different medical conditions. Risks include the use of excessive or unnecessary medications and an increase in adverse reactions to drugs. - Lack of knowledge
Different drugs interact with each other differently which is why some medicines should not be prescribed alongside others. Whenever new medicines are prescribed, a medication review should be conducted to help avoid this problem. - Poor communication
Unclear handwriting, abbreviations, and confusion between drugs with similar sounding names can lead to prescribing or administering the wrong medicine. -
Medication prescribed to the wrong patient
Drugs being given to the wrong patient can also be an issue. Similar names or changes to the order of patients on an operating list or in a clinic can result in administering medications intended for one patient to another.
Patient safety is also at risk if the correct medicine is delivered in the wrong way or where medicines are mixed up. For example, fluid bags for intravenous infusion often appear similar. Cases have been investigated where the wrong fluid has been transfused into a patient by the correct intravenous route, sometimes with serious consequences.
Prioritising patient safety
World Patient Safety Day 2022 seeks to raise awareness of the high burden of harm due to medication errors and unsafe practices. It also calls for sustained action to improve medication safety.
This requires a collective effort to engage partners to:
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address systemic problems
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encourage patients and families to be actively involved in the use of safe medication
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scale up implementation of the World Health Organisation's Global Patient Safety Challenge, Medication Without Harm.
Mistakes will happen and when they do, it is vital that services and clinicians are transparent, accountable and commit to act and improve.
Patients should also feel empowered to speak up and escalate concerns so that lessons can be learned. By learning from mistakes and committing to continuous improvement, we can all significantly improve patient safety.
