In the context of the World Patient Safety Day 2022 on September 17th promoted by World Health Organization dedicated to the Medication Safety, with the slogan ‘Medication Without Harm’, Deenova interviews Laurence A Goldberg FRPharmS, Independent Pharmaceutical Consultant. According to Mr Goldberg “An estimated 237 million medication errors occur in the NHS in England every year1. This number represents the sum of medication errors over all stages of the medication use process.”
Deenova: what are the most frequent Medication Administration Errors (MAEs) and their causes?
LAG: “Most errors occur during drug administration (54%) followed by prescribing (21%) and dispensing (16%). The most common errors were late or early administration of drugs or drug omission. Distractions and interruptions are a regular part of nurses’ working lives. If these occur when nurses are preparing and administering medicines, they can lead to drug errors that compromise patient safety. Poor numeracy and the need for complex calculations have also been highlighted as contributory factors to medication errors in both hospitals and in the community.
The majority of medication errors (72%) have little/no potential for harm and only 2% have potential to cause severe harm.”
Deenova: what are the consequences for patients and for health care organizations?
LAG: “Patients can suffer adverse effects, including irreversible damage, longer stay in hospital and higher personal costs. Organizations can suffer reputational harm, higher costs and risks of litigation. Health care workers (‘second victims’) can suffer psychological trauma and career damage.”
Deenova: is it possible to avoid medication errors?
LAG: “Yes all medication errors are avoidable. Some can be prevented through process and working environment improvement like uninterrupted medicine rounds and clear instructions and procedures. Other mistakes can be resolved thanks to software solutions such as electronic prescribing and drug administration software, electronic patient record and decision support software. Finally automation is the last mile to ensure complete closed loop medication therapies with automated dispensing and unit dose drug distribution.”
Deenova: what is the impact of automation and technology in Medication Safety?
LAG: “The implementation of automation and technology for medication management liberates the time of health care professionals for direct patient care and thereby increase the overall quality of care. For example, in Germany the introduction of UDD showed a saving of 2.61 WTE nurses per 100 beds.”
Deenova: what is the next step to bring completely safe medication practices to a wider audience?
LAG: “The development of international, multidisciplinary community hubs to share experiences and good practices. The involvement of patients is essential to develop the best safe systems. There are several websites where patients can write about their experiences (https://www.patientsafetylearning.org). Patients and relatives are often invited to speak at national and international healthcare conferences on their experiences of being the victims of medication errors that caused severe harm. Patient advisory boards and patient forums are available to advise governments, healthcare providers and also the pharmaceutical industry on safety issues.”
Deenova: how can we promote and spread ‘Medication Without Harm’ culture all over the world despite economic constraints?
LAG: “Patient safety is typically seen as a strategic priority. This sounds important, but it means that, in practice, health and social care decision-makers will weigh (and inevitably trade-off) the importance of patient safety against other priorities, like finances, resources or efficiency. Patient safety is not just another priority: it is part of the purpose of health care. Patient safety should be non-negotiable.
Medication errors, particularly drug administration errors can be reduced considerably by redesigning packaging, eliminating the preparation of doses in clinical areas and simplifying the medicine rounds. This can all be brought about at no overall additional cost to the healthcare provider by utilizing the efficiencies generated by the new practices. One of the major factors in holding up the development of these newer technologies is the pressures that healthcare workers particularly nurses and pharmacists are under at the present time. They are concerned that they do not have the time to embrace the new technologies even though in the long term, benefits will accrue.
When contracts for injectable drugs are awarded, priority should be given to those products that are presented in a RTA format. Purchasing for safety must be implemented and not just discussed.”
Laurence A Goldberg FRPharmS, Independent Pharmaceutical Consultant, UK.
September 2022
Reference
- Elliott RA, Camacho E, Jankovic D, et al. Economic analysis of the prevalence and clinical and economic burden of medication error in England. BMJ Qual Saf 11.06.2020, p. 1-10
doi:10.1136/ bmjqs-2019-010206
About Laurence A Goldberg:
Laurence A Goldberg is an independent pharmaceutical consultant working broadly in areas that are designed to reduce medication errors such as IV compounding robots, planning and organizing seminars with a focus on medication error reduction, medical devices and environmental monitoring for hazardous drugs. He was a former Non-executive Director of the National Patient Safety Agency and before establishing his consultancy service, he worked as a hospital pharmacist for over 30 years. He was designated a Fellow of the Royal Pharmaceutical Society of Great Britain in 1989 and has won several awards for his work in pharmacy. He received the UKCPA Lifetime Achievement Award in 2015 and has over 50 scientific papers to his name, many of them as sole author. For more information: lag@salt.u-net.com
About Deenova:
Since 2004, Deenova is the undisputed leading supplier of mechatronics solutions for closed loop medications and RFID-based medical devices traceability in the healthcare industry. Deenova’s unique, patented and fully integrated solutions ease the healthcare providers’ growing pressures to improve patient safety, reduce therapy errors, minimize waste and controlled substance diversion, contain costs, and diminish the gap between rising patient volume/acuity and scarce medical staff. Deenova guarantees the simplification of all processes related to the management of medications and implantable/disposable medical devices with an expected cost savings range between 15% and 25%. To know more please visit www.deenova.com or register for the Deenova Days scheduled from November 23rd to 25th.