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Re: Medication errors are NOT uncommon

We welcome the coverage given to the major, and potentially fatal, problem of medication errors within managed health care.[1] We disagree however with the key message that MEDICATION ERRORS ARE UNCOMMON. They are endemic, extremely common, overlooked and often ignored.

Observational studies of medicine administration within hospitals in the United Kingdom report an error rate of 3% to 8%.[2] In contrast Ross et al report 195 errors, collated from a mandatory error reporting policy, in 65 months.[1] While mandatory reporting is a commendable principle, the reality remains that the majority of healthcare professionals will not report errors, and the majority of medication errors, will not be reported.

Reasons for lack of reporting among nursing staff include confusion regarding the definition of drug errors and the appropriate action to take when they occurred, fear of disciplinary action, loss of clinical confidence and variation in managerial response.[3]

Voluntary, non-punitive error reporting programmes have been advocated as the most effective way to promote candid disclosure of medical error.[4] Unless we are aware of what errors occur, we cannot expect to implement an appropriate system fix.

We would suggest that the occurrence of 3 errors/month, represents a tremendous under-reporting of the extent of medication error.[1] If patient through put totalled 335,835 patient bed-days, and we assume that each day the average patient received 6 doses of medicine, an error rate of 5%, suggests that a more realistic interpretation of the extent of the error iceberg is an incidence of greater than 100,000.

The conclusion therefore that medication errors are uncommon is unfortunately not true. The reality is that REPORTED MEDICATION ERRORS ARE UNCOMMON.

Neil A Caldwell
Principal Pharmacist/Lecturer
Wirral Hospital NHS Trust/Liverpool John Moores University

Don K Hughes
Principal Pharmacist Clinical Services/Honorary Lecturer
Wirral Hospital NHS Trust/Liverpool John Moores University

References
(1) Ross LM, Wallace J, Paton JY. Medication errors in a paediatric teaching hospital in the UK: five years operational experience. Arch Dis Child 2000;83:492-7.

(2) Barber N, Dean B. The incidence of medication errors and ways to reduce them. Clinical Risk 1998;4:103-6.

(3) Gladstone J. Drug administration errors: a study into the factors underlying the occurrence and reporting of drug errors in a district general hospital. Journal of Advanced Nursing 1995;22:628-37.

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Re: Medication errors are NOT uncommon - Authors' response

We welcome the debate stimulated by our paper. Indeed, this was our aim in publishing it.

We agree with Mr Caldwell that a degree of underreporting is likely. Our system provides a clear definition to all staff of what constitutes a reportable medication error (listed in the appendix). It does not include errors that are averted such as mis-prescribed errors corrected by pharmacists prior to dispensing. We also noted that error-reporting rates vary widely in the literature. We discussed some of the reasons advanced to explain such variations, such as whether the reporting system is mandatory or voluntary and the intensity of the search for errors. However, the published evidence about medication error rates in paediatric settings is very limited especially in the context of a nationally funded, universal, health care system such as the NHS. There is, therefore, little firm paediatric evidence to support Mr. Caldwell's opposite view that errors are "…extremely common, overlooked and often ignored."

In our experience, most reported errors were minor. Serious events with adverse outcomes were uncommon and, we think, are unlikely not to be reported. If anything, we would suspect it is minor errors that are most likely to go unrecorded. This may be of considerable importance if analysis of minor events highlights system problems whose correction may help avoid future serious incidents.

Mr Caldwell suggests that voluntary systems may increase error reporting. It needs to be recognized that voluntary systems are not a panacea but may also detect only a fraction of overall errors. Again, we would suspect that minor errors might most likely be missed. The thrust of the editorial by Cohen[1] appears to relate to errors with serious adverse outcomes. There are also some potential difficulties with voluntary systems. For example, how we do we ensure that parents are notified about error occurrence if reporting is voluntary? What happens about errors of such seriousness that issues of criminal negligence arise?

Whether a reporting system is mandatory or voluntary probably is less important than that the system is non-punitive. This is borne out by the findings of Vincer et al[2] who found approximately a four to six- fold increase in the reporting of errors by reducing the punitive aspects of the form by making it an "incident" rather than an "error" form. We have no doubt that the critical challenge for us all is to make the shift from assuming "errors" arise from individual negligence to recognising that "incidents" more usually arise because of systemic organisational failures. We urgently need to move away from a culture of "fixing the blame" towards one of recognising and "fixing the problem".

References
(1) Cohen MR. Why error reporting systems should be voluntary. BMJ 2000;320:728-9.

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Re: Re: Medication errors are NOT uncommon - Authors' response

Dear Editor

This is an important area for professional discussion on a number of fronts.

In providing quality care to children and their families it is important that an integrated team approach is used. The authors (Ross et al) note how 'Most errors are not a result of individual negligence, but arise from systemic, organisational failures' (p495). In the hospital where I currently practice a recent audit of prescripition charts indicated at least 10 unreported errors from a total of 175 patient days. These were all due to organisational issues. As a team, we actively encourage nursing staff to challenge prescribing behaviours which do not endorse safe practice. Drug errors had occurred in the abouve audit largely due to misinterpretation of the prescription, which itself was a failing to comply with established good practice. Nursing staff are now instructed to:

1) insist all medications are prescribed in block capitals, using the generic meication name (unless a combination or slow release type preparation) - if a medication is not prescribed in this manner the prescriber is advised that they will be called to amend it.
2)That decimal points are NOT permissable - microgrammes and nanogrammes to be written in full
3)Where possible clear guidance regarding the frequency should be given (e.g the preffered times) (we are currently looking at removing abbreviations, as again these are another source of error)

Regarding nurses and the reluctance to report I have this to offer. In 18 years in health care I have seen many instances where nurses have reported errors and yet to see a report from a medical practitioner. My one experience where a medical practitioner administered an IV medication to the wrong child (with the nurse who checked the medication attempting to stop him) was that he received a token slap on the wrists from his consultant, the nurse received a written warning.

As humans we make mistakes, but a collaborative, team approach to minimise risk is needed to prevent error

Yours sincerely

Ian Guy BA, MA, RGN, RSCN