Improving Medication Safety

Research Theme: Healthcare Design

In most healthcare systems, the use of medicines is the dominant and often preferred method of treatment. Although the majority of medicines are used safely with little or no unwanted effects, in recent times there has been a rise in medication errors that have in some cases led to serious harm and even death. Medication errors have severe moral, political and financial implications for healthcare systems and have been associated with rising public mistrust and litigation.

Motivation

Medication errors have been described as the "single commonest cause of medical errors" (Naylor, 2002) and it is therefore important to reduce these to significantly improve patient safety.

Objectives

  • Develop a systems view of medication provision of prescription only medicinesin the NHS
  • Apply risk assessment methods to identify, analyse and evaluate risks tomedication safety
  • Develop strategies to reduce the risk identified and improve patient safety

Method

Following a systems approach, this project will look at risk across both primary and secondary care. The core activities associated with treatment with medicines (including prescribing, dispensing, administering and monitoring) will be investigated in detail. The first stage will be to understand the process and establish the context. This will be followed by risk assessment to identify, analyse, and evaluate hazards/risks in the system. A risk management strategy will then be devised and locally implemented, which will subsequently be evaluated for effectiveness. Stakeholders will be involved at each stage. This is presented in figure 1 (adapted from the FDA's risk management model). Possible risk assessment methods will include the Failure Mode Effects Analysis (FMEA); Systematic Human Error Reduction and Prediction Approach (SHERPA); and Human Error Assessment and Reduction Technique (HEART).

Details

Case studies in each activity associated with medication use will be undertaken in both primary and secondary care, with the exception of diagnosis. These are diagrammatically presented in figure 2. The process is iterative in most cases.

Prescribe:

A case study investigating risk in prescribing will be carried out in collaboration with the University of Edinburgh. Supplementary and independent prescribers will also be explored.

Dispense:

Risk assessment will be carried out to explore both automated and non-automated dispensing situations. For secondary care this will take place at Hinchingbrooke hospital pharmacy. Automated sites for primary care are likely to be limited and will be identified with the assistance of ARX Ltd (manufacturers of the Rowa automated dispensing robot).

Administer:

Medicines can be administered by a variety of professionals in hospital, including nurses, doctors, and recently pharmacy technicians. A case study here will look at risk associated with administration by healthcare professionals only. Self-administration by patients or administration by carers is considered beyond the remit of this project.

Monitor:

Careful monitoring is particularly essential with certain classes of medicines such as anti-coagulants, analgesics or those with a narrow therapeutic index, such as phenytoin. It is therefore important that monitoring is included to develop a systems view. A case study focusing on a subset of medicines where monitoring is critical will be undertaken across both primary and secondary care.

Acknowledgements

Support provided by:

  • Janet Watkinson, Hinchingbrooke Hospital Pharmacy
  • Melinda Lyons, Addenbrooke's Hospital
  • Aziz Sheikh, University of Edinburgh

Support for this project was provided by ARX Ltd and the EPSRC.

Selected Publications

  • SMITH, J (2004) Building a Safer NHS for Patients, Department of Health:London
  • FDA (1999) Managing the Risks from Medical Product Use, FDA: Washington
  • NAYLOR, R. (2002) Medication Errors, Oxon: Radcliffe Medical Press Ltd
  • LYONS, M. et al (2004) Human Reliability Analysis in Healthcare: A Reviewof Techniques, International Journal of Risk and Safety in Medicine 16: 223-237