Prescribing errors may lead to adverse events that lead to death, impaired quality of life and longer hospital stays. The cost of an ePrescribing system increased in proportion to reduced errors, reaching £4.31 per patient per year for the site that experienced the greatest reduction in prescribing errors. This estimate is based on assumptions in the model and how much a health service is willing to pay for a unit of health benefit.

To help professionals choose, set up and use ePrescribing systems in the future, the authors have produced an online ePrescribing Toolkit that, with support from NHS England, is becoming widely used internationally.

Each NHS Trust and local pharmacies in Dorset have been promoting awareness and providing updates for staff and patients on medications without harm and medicines safety following World Patient Safety Day in September. On Monday 17 October we held a face-to-face event to share learning from medicines incidents and to specifically focus on the safety improvement programme to reduce harm from opiate drugs in our communities. This provided an excellent opportunity to network with other healthcare professionals.

Speakers on the day were:

• Head of Medicines Improvement at NHS Dorset who set the scene for the morning with facts and figures for discussion.
• Clinical Lead for the Wessex Academic Health Science Network Polypharmacy programme provided an update on the wider safety improvement work.
• Patient Safety Specialist with NHS Dorset presented a patient story of a person that died following accidental fatal intoxication with liquid morphine.
• Deputy Chief Pharmacist at Dorset County Hospital (DCH) and long serving Medicines Safety officer in Dorset shared the improvement work that has taken place in DCH in relation to opiate prescribing on discharge. 
• Dr Sarah Kay, GP lead for Patient Safety with NHS Dorset, concluded the morning with a facilitated discussion session to share best practice and consider how organisations can work together to improve medicines safety.

Attendees included Primary Care Network (PCN) pharmacists, hospital trust pharmacists, NHSD patient safety teams, medicines optimisation team, primary care team, AHSNs.

In Dorset we prescribe almost double the volume of liquid opioids to patients in our hospitals when compared with others in our region. This increases the risk of prolonged prescribing in primary care, which can lead to long-term tolerance and dependency, and contributes to nearly 700 patients requesting multiple liquid opioid prescriptions each month for chronic non-cancer pain. This prescribing is having a disproportionate impact on women between 40 and 60 years of age and in more deprived areas of our county. 

 At the event, we heard from some acute trusts and PCN colleagues who are having success in reducing opiate usage and promoting safe pain management strategies for people, as well as from the Wessex AHSN who can support ongoing improvement programmes. The morning was compered by NHS Dorset Patient Safety Partner (volunteer lay role) Simon Wraw who ensured the patient perspective was part of our discussions.

The opportunity to meet face to face with colleagues was really valuable, as well as making new counterpart connections for each professional group. Feedback from attendees was positive and we hope to run a similar event in the future with a different topic focus.

On the topic of networking, we have also contributed to the setup of the NHSE South West GP Quality Network. A scoping meeting was held in October to co-produce a plan for the network with participants.

We hope to build the network, so if you work in any patient safety role across the South West and have an interest in general practice and connecting with colleagues to share good ideas and troubleshoot problems together please get in touch.

The next network meeting will be 22 February 2023. Please email england.swqualityhub@nhs.net for an invite.

Further reading

See our recent Patient Safety Spotlight interview with Sarah and Jaydee.

A medication error is defined as "any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer,” according to the National Coordinating Council for Medication Error Reporting and Prevention.

An estimated 237 million medication errors occur in the NHS in England every year.[1]  This number represents the sum of medication errors over all stages of the medication use process. Most errors occur during drug administration (54%), followed by prescribing (21%) and dispensing (16%). The majority of medication errors (72%) have little/no potential for harm, and only 2% have potential to cause severe harm.

One of the recommendations to reduce medication errors and harm is to use the “five rights”: the right patient, the right drug, the right dose, the right route, and the right time.

According to the NHS Patient Safety Strategy, “Medication errors are any Patient Safety Incidents (PSI) where there has been an error in the process of prescribing, preparing, dispensing, administering and monitoring or providing advice on medicines".  The NHS Medicines Safety Improvement Programme has been established to address the most important causes of severe harm associated with medicines and aims to reduce severe avoidable medication-related harm by 50% by March 2024.

Prescribing errors can be reduced by incorporating decision support software into the electronic prescribing protocol, although many of the warnings generated by this type of software are of no clinical significance and are often regarded as an intrusion or an inconvenience and are usually ignored. A pharmacist’s signing off a prescription before it is dispensed will also capture potential prescribing errors.

Dispensing errors are usually identified before the prescription is issued by a second check but with the introduction of dispensing/distribution robots in most hospital pharmacies, dispensing errors have almost been eliminated.

The focus today is to reduce drug administration errors. In surveys, 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.

However, many of these errors can be eliminated by the provision of medicines in a ‘ready-to-administer’ format where no manipulation is required before administration to the patient. Individual doses should have machine readable codes on the label to ensure correct drug identification.

Ready-to-administer injections (RTA)

 Injectable drugs should be made available in a ready-to-administer (RTA) format. 

The World Health Organization (WHO) defines RTA as “an injectable medicine that requires no further dilution or reconstitution and is presented in the final container or device, ready for administration or connection to a needle or administration set”.

The preparation of IV medications at the bedside requires multiple steps and reducing these complex steps and manipulations can reduce the number of errors. Additionally, the use of prefilled RTA syringes can help reduce unnecessary wastage of medications by optimising pharmaceutical product size.

Healthcare professionals responsible for administering injectable drugs should demand RTA preparations. In the first instance, hospital pharmacies should prepare high-risk injectable medicines in their aseptic compounding units or purchase them from third party contractors. Looking to the future, the pharmaceutical industry should offer licensed injectable medicines in a RTA format. Manufacturer-prepared RTA prefilled syringes can play an important role in simplifying these processes and reducing errors and potential patient harm. 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.

Unit dose drug distribution (UDD)

Unit dose drug distribution is a system that provides the prescribed dose of a specific drug for a certain patient at a specific time. It differs from other systems in that each dose of a prescribed drug is packaged individually, in a ready-to-administer form. Each dose is labelled so that it retains its identity right up to the time it is administered to the patient. The package, labelled with the drug name, strength, batch number, and expiry date, virtually eliminates contamination resulting from transfer and handling of the drug. Unused medications can safely be reissued. In addition, the system sharply reduces the potential for medication errors. For blister-packed tablets and capsules, separation of individual blisters and over-wrapping them in individual sachets has the advantage that the integrity and stability of the original pack is not compromised.

Using a ‘closed-loop’ process where the patient, the drug and the healthcare worker are identified, a safer system for drug administration can be established using unit doses with the added advantages of reduced drug wastage, reduction in nursing time and reduced inventory on the ward.

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 utilising the efficiencies generated by the new practices.

Reference

1. 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 2020:1-10. doi:10.1136/ bmjqs-2019-010206.

In unit-dose dispensing, medication is dispensed in single doses in packages that are ready to administer to the patient. It can be used for medicines administered by any route, but oral, parenteral, and respiratory routes are especially common. 

The system provides a fully closed-loop process where the patient, the drug and the healthcare professional are identified by machine readable codes and the drug administration process is linked directly to the electronic prescription and is fully recorded

There are many variations of unit-dose dispensing. As just one example, when doctors write orders for inpatients, these orders are sent to the central pharmacy. Pharmacists verify these orders and technicians place drugs in unit-dose carts. The carts have drawers in which each patient's medications are placed by pharmacy technicians—one drawer for each patient. The drawers are labelled with the patient's name, ward, room and bed number. Sections of each cart containing all medication drawers for an entire nursing unit often slide out and can be inserted into wheeled medication carts used by nurses during their medication administration cycles.

Alternatively, electronic medicine storage cabinets can be located on wards and these are attached to medicine carts which are then filled from the cabinets.

Studies often compare unit-dose dispensing to a ward stock system. In a ward stock system, bulk supplies are issued from the pharmacy; the drugs are stored in a medication room on the ward. The correct number of doses must be taken out of the correct medication container for each cycle and taken to the patient for administration. Liquids must be poured by the nurse from the appropriate bottle and each dose carefully measured.

Evidence for effectiveness of the practice

Though the practice of unit-dose dispensing is generally well accepted and has been widely implemented, the evidence for its effectiveness is modest. Most of the published studies reported reductions in medication errors of omission and commission with unit-dose dispensing compared with alternative dispensing systems such as ward stock systems. 

Potential for harm

Unit-dosing shifts the effort and distraction of medication processing, with its potential for harm, from the ward to central pharmacy. It increases the amount of time nurses have to do other tasks but increases the volume of work within the pharmacy. Like the nursing units, central pharmacies have their own distractions that are often heightened by the unit-dose dispensing process itself and errors do occur.

Overall, unit-dose appears to have little potential for harm. The results of most of the observational studies seem to indicate that it is safer than other forms of institutional dispensing. However, the definitive study to determine the extent of harm has not yet been conducted.

A major advantage of unit-dose dispensing is that it brings pharmacists into the medication use process at another point to reduce error. Yet about half of the hospitals in a national survey indicated that they bypass pharmacy involvement by using floor stock, borrowing patients' medications and hiding medication supplies.

Unit dose drug distribution is being introduced across Europe. In Germany, a recent study showed a saving of 2.61 WTE nurses per 100 beds. There is now growing interest in UK hospitals and pilot sites to develop the system are being established.

What are your thoughts on unit-dose dispensing?

Part 1: principles, practices and procedures

• Immunity and how vaccines work
• Consent
• Storage, distribution and disposal of vaccines
• Immunisation procedures
• Immunisation by nurses and other health professionals
• Contraindications and special considerations
• Immunisation of individuals with underlying medical conditions
• Vaccine safety and adverse events following immunisation
• Surveillance and monitoring for vaccine safety
• Vaccine Damage Payment Scheme
• UK immunisation schedule
• Immunisation of healthcare and laboratory staff

Part 2: the diseases, vaccinations and vaccines

• Anthrax
• Cholera
• COVID-19
• Diphtheria
• Haemophilus influenzae type b (Hib)
• Hepatitis A
• Hepatitis B
• Human papillomavirus (HPV)
• Influenza
• Japanese encephalitis
• Measles
• Meningococcal
• Mumps
• Pertussis
• Pneumococcal
• Polio
• Rabies
• Respiratory syncytial virus
• Rotavirus
• Rubella
• Shingles (herpes zoster)
• Smallpox and vaccinia
• Tetanus
• Tick-borne encephalitis
• Tuberculosis
• Typhoid
• Varicella
• Yellow fever

Medication safety - Cause and effect template

Medication safety - Impact matrix

Medication safety - Roles and responsibilities matrix

Medication safety - Self assessment

Medication safety - Stakeholder analysis matrix 

These conjoint "opioid epidemics" have heightened and stirred conversations about prescribing and regulatory practices, "war on drugs" rhetoric, the "fifth vital sign," opioid accessibility, prescription rates, and effectiveness of opioids for non-cancer chronic pain, among many others.

With the rise in opioid use and death, a review of the many and sometimes paradoxical expressions of akathisia is warranted.