Tough stuff


Did you see the BBC headline;

‘Drug errors cause appalling harm and deaths, says Hunt…’

There’s new research.  What does it actually tell us?

‘GPs, pharmacists, hospitals and care homes may be making 237 million errors a year – the equivalent of one mistake made for every five drugs handed out.

… and it says;

‘most caused no problems, but in more than a quarter of cases the mistakes could have caused harm… drug errors could be a factor in more than 22,000 deaths a year.’

Read that carefully.  ‘May be making’ errors.  ‘Most caused no problems’.  ‘Mistakes could have caused harm’.  ‘Drug errors could be a factor’.

In fairness, the researchers from Manchester, Sheffield and York Uni’s distance themselves from firm conclusions…they say;

‘…there is limited data in this area…  the figures are very much ‘best estimates’… based on previous research, some of it going back years.’

So, we have limited, old data, re-interpreted to create guesses and extrapolations about something that might be happening now… or not.

I’m no academic but this looks, to me like lucky-dip, car-boot sale research.

The report focuses on the fact that ‘A fifth of mistakes relate to hospital care…’  hence the Tinkerman is talking about ‘hospital solutions’ such as; electronic prescribing, decriminalising errors and better packaging.

He’s looking in the wrong place…  the majority (4/5ths) of mistakes take place elsewhere, making the Hospital the least dangerous place.

The research estimates that 71% of the 270m annual drug ‘errors’ occur when patients see a GP or practice nurse.  Where they already have electronic prescribing.

To give some context; 1.15 billion drug prescriptions are written each year.  I figure that means about 2,000 prescriptions a minute.

The Tinkerman says;

‘We’re seeing four to five deaths every single day because of errors in prescription, or dispensing, or the monitoring of medications.’

Four or five?  That’s 1,460 or 1,825 annual deaths.  Which?

The Guardian headline…

‘Hunt to crack down on NHS drug errors linked to up to 22,000 deaths…’

Actually, according to the Uni’s who did this work, they guess at 700 deaths, attributable to drug errors.

So, we have extrapolations from old numbers, with lazy journalism, egged on by the Secretary of State on a mission.

Where do we start to try and find a way out of the hyperbole and into seriously managing the problem?

Drug errors; the leading cause of patient harm in health systems across the world.  In fairness, we do a lot better than most. 

For a sober, sensible look at the issue, try this WHO report.

The biggest likely error-source?  Care homes. 

WHO studied 15 nursing homes and found that;

  • 46.5% of the residents received at least one inappropriate medication and …
  • 9% of all prescribing events in care homes were subject to error,
  • with 70% of care home residents affected by a medication error.

Extrapolate that!  It tells me where we should make a start.

The CQC have their own vague ideas about quality in care homes.  They’re costly, allow nonconformance and can we but conclude; care homes are likely, the most dangerous places? 

This, very clear analysis, of, I think, a better report confirms it.  And the CQC’s annual report continues to highlight medication errors. 

Inspection does nothing to help and there is no rigour in care home reporting mechanisms.

Solutions don’t involve rocket science.

Six Steps:

  1. Figuring out what we’re doing,
  2. Asking if it’s what we want?
  3. Put things in place to make sure we get it,
  4. all the time,
  5. every time
  6. … until we decide to do something better.

… simple management.  Yup, but it requires a level of openness and transparency the NHS struggles with and how do we find out what goes on behind the closed doors of a care home?

You can’t… unless you shift thinking, from; ‘what error did you make’ to ‘why did the mistake happen.’

Of all the things you will hear said in care services, ‘I have made a mistake…’ is the one you will hear least often, when, if we take the data at face value, we should be deafened by it.

Drug errors;

Soft risk; hospitals, easily fixed.  Good systems and good practice examples, supervision, some IT investment.

Harder risks; GP surgeries who already have electronic controls and qualified staff.  Resistance to outside scrutiny. 

The tough risks; care homes; sector-wide economy failing, poor investment, manual systems, low skill-levels, language issues, poor supervision and sloppy reporting.

Message; stop tinkering, take on the tough stuff. 


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Reproduced at by kind permission of Roy Lilley.