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Friday, 23 February 2018

OUTRAGEOUS: NHS: "Drug mistakes killing up to 22,300 patients a year"

February 23 2018, 12:01am, The Times

A report has recommended ending handwritten prescriptions in a bid to avoid potentially fatal drugs errors

A report has recommended ending handwritten prescriptions in a bid to avoid potentially fatal drugs errors
Handwritten NHS prescriptions must end, the health secretary will say today as a report concludes that errors involving dispensed medicines kill up to 22,300 patients a year.

NHS staff make 237 million drugs errors every year, more than a quarter of which injure patients and cost up to £1.6 billion, a study ordered by the government has found.
Jeremy Hunt intends to stop the “appalling levels of harm and death” that result from doctors prescribing the wrong dose, pharmacists handing out the wrong medicine and nurses mixing up patients. He has set a five-year target to halve harm from drug mistakes.
About one in 12 prescriptions is thought to contain an error and the World Health Organisation has said that such mistakes are a leading cause of death during treatment. Staff have complained about medicines with similar names and packaging, equipment with the “off” switch next to key controls, and non-standardised prescribing systems that tend to make mistakes more likely.
In a speech to the Patient Safety Conference in London today Mr Hunt says: “This new study shows medication error in the NHS and globally is a far bigger problem than generally recognised, causing appalling levels of harm and death that are totally preventable.”
Two thirds of hospitals and some GPs still write paper prescriptions and Mr Hunt will highlight illegible handwriting as one cause of mistakes, pledging a share of a £3.5 billion infrastructure fund to make electronic prescriptions universal.
“It can’t be right that hospitals are recording vital information like prescriptions using pen and paper, yet only one third of trusts use e-prescribing effectively, despite these systems halving the risk of error,” Mr Hunt says.
A system that links prescriptions data to hospital admissions will help to spot when illness is the result from changes in medicines, he adds.
Pharmacists will no longer be prosecuted for honest medication mistakes and similar changes for doctors and other staff are being considered after an outcry in the medical profession over the manslaughter conviction of Hadiza Bawa-Garba, a junior doctor, for mistakes that led to the death of a six-year-old boy.
Mr Hunt adds: “Part of the change needs to be cultural: moving from a blame culture to a learning culture so doctors and nurses are supported to be open about mistakes rather than covering them up for fear of losing their job.”
More than half of prescription mistakes happen when drugs are given, and a fifth when prescriptions are written, according to an overview of 36 studies by researchers at the University of York, Sheffield and Manchester. Their model suggests that errors definitely kill 1,700 patients a year and probably play a role in a total 22,300 deaths.
Mark Sculpher, one of the authors of the study, said that there were errors “over the whole spectrum”, from writing prescriptions through picking up drugs to administering medication and reviewing how patients responded.
Case study

Dr Mike Stevenson accidentally injected a patient with six times the correct dose of diamorphine
Dr Mike Stevenson accidentally injected a patient with six times the correct dose of diamorphine

When Dr Mike Stevenson reached into the medicine cabinet in his surgery before rushing to a house call he picked up a familiar-looking box (Chris Smyth writes).
The result was the death of Marjorie Wright, 58, after he accidentally injected her with six times the correct dose of diamorphine.
Stevenson was convicted of manslaughter and struck off in 2009 after admitting the fatal error. He received a 15-month suspended sentence. He does not challenge the verdicts but argues they have done little to protect patients.
“I picked up the wrong box. The colour looked right but all manufacturers have different colours,” he said. “I picked up a potentially lethal vial, but 2.5mg comes in exactly the same box as 30mg or 100mg.”
Stevenson did not notice his error when injecting the medicine as the dose was labelled in such small type.
“It seemed obvious to me that we need to be learning from this but nothing happened,” he said.