Medication Safety: How patients and healthcare professionals make safety work

Medicines are the most common healthcare intervention in the NHS. It is increasingly important that healthcare professionals work collaboratively with patients to minimise harm from medicines. Natasha Callender, Pharmacist, and Medicines Workstream Lead for Patient Safety shares some reflections on what the opportunities are.

More than 200 million medication errors occur in the NHS each year. Most errors occur in administration, prescribing and dispensing. Most medication errors have little/no potential for harm, and only two per cent have potential to cause severe harm. The majority of errors are associated with administration. Tried and tested safeguards such as the 5 Rights of Medication Administration - the right patient, drug, dose, route, and time – are widely accepted ways to reduce medication administration errors.

While humanistic safeguards can mitigate risk of medication errors, there is increasingly a place for using technology to improve the safety of systems, for example during transfer across traditional care boundaries between hospitals and general practices/primary care networks; or closed loop medication and administration prescribing systems in hospitals. I recently attended the Patient Safety Congress where speakers who shared their progress on implementing closed loop medicines administration, and suggested that standardisation was the way forward to reduce medication errors.

However closed loop administration and other digital solutions will not reduce all medication risks. At the Health Innovation Network, we have been facilitating our Opioid Stewardship Quality Improvement Collaborative with the aim of helping healthcare professionals improve chronic pain management for patients. As part of this programme, we watched a video about asking the ‘5 Whys’ to reach the root cause of a problem. Fixing the actual root cause may be far more simple and inexpensive than the alternatives.

Improving pathways or services to reduce harm from medicines does not always require complex or expensive solutions, but collaboration remains a crucial part of the process. By involving patients and allowing them to personalise their own care, we can make simple changes that have a significant impact. It is important to engage and co-develop improvements with patients when improving services. There is a lot we can learn from their experiences to inform changes for the better.

At the core of the Medicines Safety Improvement Programme (MedSIP) that drives our local medicines workstream, is a quality improvement approach. But it is through reporting of adverse events to national data schemes that trends can be identified as areas of improvement. Both patients and healthcare professionals are encouraged to report suspected and actual adverse events from medicines and vaccines via the Yellow Card MHRA reporting service. Together we can work to ensure adverse experience with medicines drive the improvements we strive to make.

Resources

Yellow Card scheme or via the Yellow Card app (download from the Apple App Store or Google Play Store) – only a suspicion is needed to report a suspected reaction.

For suspected adverse reactions associated with COVID-19 vaccines and medicines, as well as suspected incidents with medical devices and test kits, report directly to the Coronavirus Yellow Card reporting site or use the Yellow Card app.

References

1. EEPRU 2018: Prevalence and economic burden of medication errors in the NHS in England
2. NHS England: Enduring standards that remain valid from previous patient safety alerts