Patient safety is fundamental in any healthcare system. However, medication errors can and do occur within those systems.

The World Health Organisation (WHO) has a goal to reduce severe avoidable medication-related harm by 50%, globally by 2022 via its Global Patient Safety Challenge: Medication Without Harm.

To achieve this, pharmacists need to share data about medication errors so lessons can be learned. Not just at a local level, but on a national and international level.

A recent article in the Pharmaceutical Journal outlined the scale of the problem that Pharmapod helps to address.

237.4 million errors in England each year

Each year, a total of 237.4 million errors are made each year in England alone. This results in 712 deaths due to avoidable adverse drug reactions each year. It is also costly; the NHS loses £98.5m through preventable adverse drug reactions per year.

The most significant types of error included omitting medicine or an ingredient (21.3%), a wrong or unclear dose or strength (11.5%) and the wrong frequency (8.0%).

UK medication errors - Dawn Connelly and Martin Cotterell
Source: Property of Dawn Connelly and Martin Cotterell

Where do errors take place?

The most significant volume of errors take place in the care sector (99.0m, 41.7% of the total) but these tended to be less severe; 88.7% were minor incidents with little or no potential to cause harm.

In primary care, 91.0m events took place (38.3% of the total), and incidents were more likely to have a serious impact: 3.5m had the potential to cause severe harm.

In secondary care, 47.2m incidents took place (20.0% of the total) of which 38.5m were minor, 8.0m were moderate, and 0.9m were severe.

Dispensing errors account for 17.5% of errors that have the potential to cause moderate or severe harm in primary care.

Medication errors - Dawn Connelly and Martin Cotterell
Source: Property of Dawn Connelly and Martin Cotterell

Which stages of medicine use are most prone to error?

By far the most errors take place in drug administration; 129.1m incidents took place at this stage or 54.4% of the total. The drug administration stage accounted for 400,000 severe incidents and 9.4m moderate incidents.

Prescribing errors are most likely to cause moderate harm (41.2% of moderate errors occur at this stage) while dispensing errors account for 17.5% of errors with the potential to cause moderate or severe harm in primary care. Monitoring errors represent only 7.0% of total errors but the highest level of severe errors (2.7m).

How can you help in reducing medication incidents?

In their summary of recommendations published by the Department of Health and Social Care in their report ‘The report of the short life working group on reducing medication-related harm’, February 2018, they included:

  • Professional regulators and professional leadership bodies should also encourage reporting and learning from medication errors.
  • The development of a prioritised and comprehensive suite of metrics on medication error aimed at improvement.
  • Development of a repository of good practice to share learning.
  • New research on medication error should be encouraged and directed down the best avenue to facilitate positive change.
  • Improved shared care between health and care professionals; with increased knowledge and support.

Without precise data, nothing will change. An accurate picture of errors enables informed decisions to be made, both at an organisational and an international level.

Pharmapod is fully aligned with these recommendations as our SaaS platform enables pharmacy professionals to anonymously record dispensing errors and outcomes, to protect themselves and the public in the future.

To learn more about how Pharmapod is helping facilitate change within pharmacy practices, get in touch below.  Is it time you joined in to help drive this change?

Note: All images used in this post are the property of their respective owners.