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A new study, published by the Economics Evaluation of Health and Care Interventions (EEPRU), has reported that an estimated 237 million medication errors occur in the NHS in England each year.
Prof Sir Munir Pirmohamed, President-Elect, British Pharmacological Society, David Weatherall Chair of Medicine at the University of Liverpool, and NHS Chair of Pharmacogenetics, said:
“The report by Elliott et al highlights the appalling burden of medication errors on the NHS, in all settings. It makes the case that a consequence of the medication error is to lead to an adverse drug reaction, which can itself result in hospitalisation and death. This does not surprise us, as we have highlighted in several of the reports from the British Pharmacological Society[1].
“The report leans heavily on two papers which were undertaken in 2004 and 2009 (references 15 and 17 of the report[2]), which are still hugely relevant. Indeed, given the increasing elderly population, and the increasing tide of polypharmacy, the figures may be even worse in 2018. Frighteningly they are not likely to improve, unless some drastic action is taken.
“What is clear is that this complex issue does not have a single solution. It needs a multi-component approach, one of which involves increasing quality and standardising education and skills. We must also increase the number of clinical pharmacologists in the UK, to work in partnership with their clinical pharmacist colleagues, especially in primary care.
“The British Pharmacological Society has recently formed the Clinical Pharmacology Skills Alliance[3] together with the ABPI, Faculty of Pharmaceutical Medicine and Health Education England, to develop a plan to increase the number of clinical pharmacologists working in the UK, both in the NHS and Industry, and to address this complex issue at a fundamental level. We are committed and ready to help.”
[1] https://www.bps.ac.uk/about/our-campaigns/clinical-pharmacology-the-nhs
[2] Pirmohamed, M., James, S., Meakin, S., Green, C., Scott, A.K., Walley, T.J., Farrar, K., Park, B.K. ,Breckenridge, A.M. (2004). Adverse drug reactions as cause of admission to hospital: prospective analysis of 18 820 patients. BMJ. 329: 15-19.
Davies EC, Green CF, Taylor S, Williamson PR, Mottram DR, Pirmohamed M (2009) Adverse drug reactions in hospital in-patients: a prospective analysis of 3695 patient-episodes. PLoS ONE 4: e4439.
[3] https://www.bps.ac.uk/news-events/news/articles/2017/clinical-pharmacology-skills-alliance-launched-to
Prof David Webb, Past-President, British Pharmacological Society, Co-Chair, Prescribing Safety Assessment, and Christison Professor of Therapeutics and Clinical Pharmacology at the University of Edinburgh, said:
“The catastrophic effects of errors in prescribing in the UK is well known, and the effects on patients can be devastating. There are solutions, such as the Prescribing Safety Assessment, led by the British Pharmacological Society and Medical Schools Council, which puts the training and education of our medical students first, and aims to allow them to understand the skills and competencies they need for a lifetime of treating patients. There is also currently a concerted effort being made by a broad cohort of organisations to put Clinical Pharmacology skills, which underpin our knowledge of how drugs work in patients, at the heart of safe prescribing practice in the NHS. What is needed now is a joined up effort to support that work, and to embed it across all of the prescribing disciplines in the NHS. The British Pharmacological Society has safe prescribing at its core and is ideally placed to help.”
Prof Martyn Thomas FREng, Livery Company Professor of Information Technology, Gresham College and Visiting Professor in Software Engineering at the Universities of Oxford, Aberystwyth and Bristol, said:
“Medication errors are a very serious problem and it is often wrong to blame the medical staff when the root cause is often poorly designed and implemented computer systems. A US study found that a quarter of medication errors were computer related. Prof Harold Thimbleby and I have already proposed some steps that would certainly reduce the errors – and the deaths and injuries that result from them1.
“Jeremy Hunt says that a greater reliance on IT, such as electronic prescribing, is part of the solution. This is only true if those IT systems are properly designed and implemented.”
1 http://www.harold.thimbleby.net/killer.pdf
Prof Simon Maxwell, Fellow of the British Pharmacological Society and Clinical Pharmacologist, University of Edinburgh, said:
‘The report is a helpful summary of a complex part of the patient safety agenda. E-prescribing, medicines management and safety culture will all play a role in improving outcomes, but education and assessment must lead the way. Unless those who are charged with prescribing and administering medicines have sound knowledge to underpin the important judgments they must make, patients will continue to suffer avoidable harm.
‘The Prescribing Safety Assessment has built confidence among prescribers in their skills and abilities, as well as forcing those who do not reach basic standards to undergo further training. I would like to see that same approach taken across all prescribing groups in the UK to truly address the issue of prescribing safety among an increasingly diverse group of prescribers.’
*The Prescribing Safety Assessment (PSA) has been developed as a collaboration between the British Pharmacological Society and Medical Schools Council in the UK. The assessment allows all students to demonstrate their competencies in relation to the safe and effective use of medicines. The international version of the PSA can be accessed via: www.prescribingskillsassessment.com
Declared interests
None received