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Dispensing defence one of Hunt’s ‘ground-breaking’ plans to end errors

Research suggests that 72% of over 200 million medication errors have little or no potential for harm
Research suggests that 72% of over 200 million medication errors have little or no potential for harm

Health secretary Jeremy Hunt has set out three “ground-breaking” measures to tackle 200 million medication errors across the NHS each year.

Mr Hunt – who set out the initiatives at the Annual World Patient Safety, Science and Technology Summit in London today (February 23) – said they will help to tackle the “appalling levels of harm and death that are totally preventable”.

One of these is the legal defence from criminal sanctions for pharmacists and staff who make an inadvertent dispensing error, which could become law as early as April.

This “will ensure the NHS learns from mistakes and builds a culture of openness and transparency”, the Department of Health and Social Care (DH) said today.

Another is a new system “linking prescribing data in primary care to hospital admissions”, which will help identify “if a prescription was the likely cause of a patient being admitted to hospital”, Mr Hunt said.

This will initially focus on how different medicines may be contributing to hospital admissions linked to gastrointestinal bleeding, and will be rolled out to “a broader range of medicines” following an evaluation in the spring.

Mr Hunt also plans to “accelerate the introduction of electronic prescribing systems” across “more NHS hospitals”, which “could reduce errors by up to 50%”, the DH said in a statement ahead of his speech.

237m medication errors a year

Mr Hunt's announcement came in response to new research published today by the Universities of Sheffield, York and Manchester, which estimates that “237,396,371 medication errors occur at some point in the medication use process in England” per year. Prescribing errors and dispensing errors account for 21% and 16% respectively, while 54% were “administration errors”, the report’s authors said.

However, of the 237m errors, 72% have little or no potential for harm and “not all these errors would have reached the patient”, the authors stressed.

These medication errors account for 1,708 “definitely avoidable” deaths, according to the research.

The findings, based on 36 studies of “error rates in primary care, care homes and secondary care, and at the various stages of the medication pathway” are “at least 10 years old, so may not reflect current patient populations or practice”, the authors added.

Read a full copy of the report here.

Community pharmacy prevents errors

Responding to the research, National Pharmacy Association (NPA) chief pharmacist Leyla Hannbeck said patient safety is “deeply ingrained in the minds of community pharmacists, who dispense more than a billion prescription items each year”.

“It’s estimated that pharmacists query about 6.6m of those items, helping resolve many incidents that might otherwise have resulted in serious harm,” she added.

Janice Perkins, chair of the Community Pharmacy Patient Safety Group – which consists of representatives of all of the larger pharmacy chains, as well as the NPA – said the organisation is “committed to supporting healthcare leaders” implement Mr Hunt’s initiatives.

“Community pharmacists and their teams play a vital role in preventing medication errors, intervening on prescriptions and minimising risks to patients every day,” she said.

Greater access to patient records

“Discharge medication reviews taking place in community pharmacies, and community pharmacy read/write access to the GP patient record, would be significant enablers” to closer working between general practice and pharmacy teams, Ms Perkins said.

Royal Pharmaceutical Society (RPS) English pharmacy board chair Sandra Gidley also called for pharmacists to receive greater access to “vital information from a patient's record, to enhance safety”.

“Pharmacists can and have been playing a vital role in reducing medication errors through transfer of patients between care settings,” she added. “We strongly believe that every care home should have a named pharmacist dedicated to improving medicine safety.”

C+D clinical editor Kristoffer Stewart appeared on BBC News this morning calling for pharmacy to have read/write access to patient records.

GPhC: We want to play our part

The General Pharmaceutical Council (GPhC) said it “strongly agrees” that “it is vital to have a learning culture across healthcare”.

“We will continue our work to promote a culture of openness, honesty and learning across pharmacy, and we will be urging everyone who employs pharmacy professionals or works within pharmacy to do the same,” chief executive Duncan Rudkin said.

Numark managing director Jeremy Meader said: “Pharmacy takes great pride in dispensing prescriptions accurately, as evidenced by the significantly low numbers of dispensing errors that occur.”

Mr Meader commended Mr Hunt’s support of the legal defence for dispensing errors, and said Numark “will be seeking further dialogue with Jeremy Hunt to continue to promote the vital role that community pharmacy plays”.

18 Comments
Question: 
How will these measures affect the number of dispensing errors?

Sachin Badiani, Pharmacy owner/ Proprietor

That is partly due to some far away surgeries not accepting repeat requests via scan and email, or that surgeries have not implemented ETPR2 yet. Hence, the fax machine to the rescue.

Edit: This post was a reply to Benjamin Leon D'Montigny's  post at the bottom.

Ilove Pharmacy, Non Pharmacist Branch Manager

Editor is there any particular reason the Boots Basingstoke error has not been covered ?

Amal England, Public Relations

I find these figures hard to believe! Retail pharmacy organisations (NPA,PSNC) should get together and come with a figure for community pharmacy.
Can C&D please explain what Jeremy has done towards decriminalising accidental errors in community pharmacy?
PS: medication errors are still a criminal offence until your lawyer gets you 'off the hook' with this legal defence facade! AND it does not cover OTC sales! AND it does not stop your employer from giving you the sack for accidental errors!
Pharmacy leadership is paper thin, the Pharmacy regulator is a mistress for the multiples, too many pharmacists are in a coma, many more are sleep walking..... Thinking of doing pharmacy?

Jonny Johal, Pharmacy Area manager/ Operations Manager

Amal, I am not surprised by these figures, I have seen more unreported errors in my time than 'reported' ones, and my impression is they are increasing in frequency, especially amongst the more recently qualified pharmacists. Some of them are not even bothered about errors (that's why I would oppose decriminalisation), I met one pharmacist who is more concerned about what he can get away with than not making errors. My experience is very few errors are accidental, most I came across were due to negligence, or recently, even semi-deliberate e.g. one I remember is when a doctor ordered a special manufacture item A, the pharmacist ordered item B (by mistake), and then generated a label for item C (deliberately, because he didn't know how to do special labels on Nexphase!).

Amal England, Public Relations

I think as an area manager you will have good insight into the numbers of reported and unreported errors. The next thing is to ask why?
You met ONE pharmacist.... So the law should be changed because of this one pharmacist. If you are implying that there are more non-accidental errors than accidental errors then you stand alone. The overwhelmingly view, across a plethora of professions is that most errors are accidental and when the criminality element is eliminated and an open environment is nurtured, these errors become a valuable means to learn and prevent errors from recurring, especially the serious errors. The very nature of the human is to make mistakes, the very nature of the profession is that mistakes will be made.... That is why the law states you must have professional indemnity insurance. As an area manager you will have seen many errors and the reasons and how the same errors happen again for the same reasons.... That is because virtually nothing is done to deal with those reasons.

Mohammed Patel, Community pharmacist

There's a very easy way to reduce dispensing errors in pharmacy. Create and enforce sensible minimum staffing levels using an equation which uses both dispensing volume and services provision. Easy peasy! 

The problem is, that, the people who are actually in charge will deny ever reading this tiny little comment to a C&D article. Yet every pharmacist in the UK understands the situation. So why are the powers that be choosing to ignore it?

Corruption? Nepotism? Cronyism?

Whatever it is, the UK pharmacy industry is refusing to focus on what actually matters and just keeps plodding on with this petty rubbish just so that certain people can stay employed and keep working towards that pension pot (and that's very important to greedy people). Two fingers up to the patient facing qualified people who are actually doing the real work.

Jonny Johal, Pharmacy Area manager/ Operations Manager

These figures gives us perspective on the scale of errors under-reporting. We can't really move forward until we recognise that pharmacists are part of the problem, and not yet the answer.

Mohammed Patel, Community pharmacist

Pharmacists are just doing what they were trained to do in their 4 year masters and pre reg. However, they soon realise that it was all moot because the employer just wants you to fill in forms with medical jargon for 28 quid a pop.

Ilove Pharmacy, Non Pharmacist Branch Manager

You forgot persuading Mrs Jones, 79 years old, to sign the consent form.

Adam Hall, Community pharmacist

Will this extension of EPS get as far as Dispensing Doctors?

Stephen Eggleston, Community pharmacist

What is the point of basing anything like this on evidence which is 10 years old? 10 years ago, I suspect we were just introducing the idea of near miss logs in to pharmacy, and scanning barcodes on prescriptions to reduce errors were a dream. I also noticed, when I saw this report on the BBC this morning, there was no mention of the age of the data used, or the fact it no longer reflected current processes

Jonny Johal, Pharmacy Area manager/ Operations Manager

Do you have any better statistics to quote? Any evidence that things have got better? My subjective personal impression is that things have got worse in recent years.

Kevin Western, Community pharmacist

Careful what you wish for! scanning starts next year to ensure we arent dispensing tablets we knocked together in the garage. it will be a huge burden given the way its written, last I looked. 

What concerns me is Hunt's apparent confusion between decriminalising - ie its not a criminal offence and a defence - ie if you were good we will let you off

Ilove Pharmacy, Non Pharmacist Branch Manager

I wonder if Boots/GPhC will adhere to this new era of openness. Something tells me...... 

Mohammed Patel, Community pharmacist

Some people on here have suggested that Boots and the GPhC are so intertwined that they can be considered one and the same. Hence the GPhC ignoring the glaring issue of workplace pressure and stress. Because the answer is to spend more on staff and Boots don't want that because the CEO might not be able to afford his next yacht/Picasso.

Ilove Pharmacy, Non Pharmacist Branch Manager

Not something C&D seem to want to cover for some reason.....

thepharmacist Forever!, Pharmacist Director

I am alarmed why we in community pharmacy are not given the scanning technology that is seen in many dispensing practices, which then utilises the barcode for an additional accuracy check!

But seeing the statistics above, show that the majority of errors are in administering, therefore matters outside of pharmacy.

Congratulation to all the hard working dedicated pharmacist for doing such an amazing job, looking after patients so well, in such a challenging time in the NHS, I have to say without us, the level of patient harm would be through the roof!

In simple, pharmacist save lives - NHS help us and we will save more!, Fund us properly and see what we can do!  - Jeremy Hunt - please take this challenge and lets meet in a year and see the results.

 

 

 

Leon The Apothecary, Student

I believe we are certainly behind the times when it comes to available technology and what we actually use. I mean, firstly - we still use fax machines en masse.

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