Opinion  

In June the National Patients Safety Agency (NPSA) published the fourth report from the Patient Safety Observatory, entitled Safety in Doses: medication safety incidents in the NHS. 'Yet another document to read!' I hear you say. Well, yes I'm afraid so, but hold on a second. This document really is a must read for all staff who deal with medication.

Every day, about 2.5 million medicines are prescribed in the community and in hospitals in England. Most prescriptions are delivered correctly and do exactly what they are meant to do. However, 60,000 errors were reported to the NPSA via the National Reporting and Learning System (NRLS) between January 2005 and June 2006, at a cost to the NHS of £750 million. Safety in Doses reports on these errors and how to minimise them in the future.

Primary care reports fewer errors
Most medication activity (prescribing, dispensing and administering) occurs in the community and a quarter of NHS organisations, mainly in primary care, report no medication errors whatsoever. Indeed, medication errors reported in primary care account for just under 20 per cent of all those reported to the NRLS.

However, the low percentage of errors reported is not necessarily a sign of better practice, but may indicate that reporting systems are deficient or that medication errors aren't picked up so easily in the community setting. This is a great shame, as such data would highlight where errors occur and save money. More importantly, it would help to reduce patient pain and suffering and, in some instances, severe harm or death.

Having said that, the report does highlight that certain types of incident in primary care are reported more frequently than others. One such example is the reporting of incidents concerning the administration of vaccines, a role routinely performed by practice nurses. It is suggested that practice nurses have a culture of reporting that is 'far more developed than it is among GPs'.

Examples of individual errors and their consequences are provided in the NPSA report. It is evident that in the community setting (general practice, community pharmacies, care homes and patients' own homes), the two most commonly reported incidents are wrong medicine or wrong dose. It is suggested that communication/documentation and the transfer of care between primary and secondary care are areas that require further exploration in order to prevent future incidents.

How practice can improve
The report also provides examples of how local practice may help to prevent future errors. Seven key action points to improve medication safety are described. These include: increased reporting and learning from medication incidents; the implementation of NPSA safer medication practice recommendations; improvement in the skills and competencies of staff; minimising dosing errors; ensuring medications are not omitted; ensuring the correct medicines are delivered to the correct patients; and documenting patients' medication allergy status.

Errors occur at every stage of medication management. Therefore anyone (doctor, nurse, pharmacist or dispensing technician) involved in these stages should make an effort to read this report and promote it among colleagues. Our patients deserve a safe and professional service. Statistically, we as individuals, and our loved ones, will almost certainly be victims of medication errors one day. Many of these errors could be prevented.

Further reading
National Patient Safety Agency. The fourth report from the Patient Safety Observatory, Safety in doses: medication safety incidents in the NHS.

Available from www.npsa.nhs.uk. Hard copies available via 08701 555455.

- Professor Matt Griffiths and Professor Molly Courtenay are joint RCN prescribing and medicines management advisers. Professor Griffiths is also senior charge nurse at Peterborough Walk-in Centre and visiting professor in prescribing and medicines management at the University of Northampton. Professor Courtenay is professor of prescribing and medicines management at Reading University

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