This year's World Patient Safety Day, due to take place on Saturday 17 September 2022, will focus on medication safety, promoting safe medication practices to prevent medication errors and reducing medication-related harm. In this blog for the hub, Laurence Goldberg, an independent pharmaceutical consultant, looks at how we can reduce drug administration errors by the provision of medicines in a ‘ready-to-administer’ format where no manipulation is required before administration to the patient.
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. 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.
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.
About the Author
Laurence is an independent pharmaceutical consultant working broadly in areas that are designed to reduce medication errors such as IV compounding robots, planning and organising seminars with a focus on medication error reduction, medical devices and environmental monitoring for hazardous drugs. He is former NED of the National Patient Safety Agency.