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National Patient Safety Agency

Tackling medication incidents and increasing patient safety

Thursday 3 September 2009


A review of medication incidents across the NHS in England and Wales has been published today (3 September) that aims to help ensure that medicines are used safely and prevent similar incidents from happening again.


Safety in doses, published by the National Patient Safety Agency (NPSA), identifies risks and areas for action based on a detailed analysis of 72,482 medication incidents.


The number of reported incidents has increased significantly, indicating that the NHS has improved its reporting culture and is willing to come forward when mistakes have been made. The majority of the reports resulted in no or low harm to patients.


The medication incidents were reported to the NPSA by frontline NHS staff in acute, mental health and primary care sectors between January and December 2007. Trends in these incidents were analysed and have been translated into actions and safety opportunities for frontline services.


NPSA Chief Executive Martin Fletcher said:


“Millions of medicines are prescribed in the community and in hospitals across England and Wales each day – the majority of these are delivered correctly and do exactly what they are meant to do. However when an incident does occur, it is vital we learn from this to ensure patients are not harmed.


The Safety in doses report includes examples of how local practice may help to prevent future incidents.  Examples of action points for NHS organisations include:


  • review the number and quality of medication incident reports received locally and identify whether current arrangements are enabling local learning and action to minimise risk of harm to patients;

  • use the information and examples in the report to risk assess and improve local medication systems.

The review’s main conclusions found the most serious incidents were caused by medicine administration (41 per cent), followed by prescribing (32 per cent).


It also found that after previous guidance issued by the NPSA around the safe use of potassium chloride injection and oral methotrexate, there were no further incidents of death or severe harm in 2007 involving these medicines.


NHS Medical Director, Sir Bruce Keogh said:


“I welcome this report from the National Patient Safety Agency. Patient safety is the highest priority for the NHS and the Government. The vast majority of NHS patients experience good quality, safe and effective care and this is reflected in today’s figures which show that the majority of medication incidents, 96 per cent, had clinical outcomes of low or no harm to patients.


“However, we expect all NHS organisations to examine the NPSA’s recommendations carefully and where necessary take steps to implement them in order to ensure that the services they provide are as safe as possible.


"We have learnt from industries, such as aviation, that scrupulous reporting and analysis of safety related incidents, particularly 'near misses', provides an opportunity to reduce the risk of future incidents. Through the NPSA, the whole of the NHS can learn from the experiences of individual organisations."


Gillian Cavell, Consultant Pharmacist at King’s College Hospital NHS Foundation Trust said:


“This report highlights the fact that serious medication errors can happen in any trust. Existing guidance from the NPSA is helpful in emphasising the fact that trusts need to remain aware of the risks associated with medicines.  We all need to follow these recommendations and implement new systems if necessary to ensure that we remain compliant with the guidelines at all times.


“The powerful case studies included in the report, particularly those associated with serious harm and death, should encourage pharmacists as part of multidisciplinary teams to reflect on the effectiveness of local systems to prevent similar devastating incidents from occurring in our own organisations.“


Martin Stephens, National Clinical Director for Hospital Pharmacy and Jonathan Mason, Primary Care and Community Pharmacy at the Department of Health said:


"This report is very encouraging – particularly that the coordinated response to the potassium chloride and methotrexate guidance has decreased the number of incidents associated with these medicines – the NHS is recognising and learning from incidents. However, more still needs to be done. In the light of the incidents involving prescribing and administration, we will be calling on our pharmacy colleagues throughout the NHS to work with prescribers and those involved in medicines administration to help reduce the risks associated with these activities."


Read the Safety in doses: improving the use of medicines in the NHS report. 





Notes to Editors:


Media enquiries to the NPSA Press Office:

Simon Morgan – 020 7927 9580 / simon.morgan@npsa.nhs.uk

Paul Cooney – 020 7927 9351 / paul.cooney@npsa.nhs.uk

Out of hours – 0788 411 5956 / press.office@npsa.nhs.uk.

The NPSA has established a Clinical Board for Medication Safety made up of the leading bodies in medicine, pharmacy and nursing as well as other associated stakeholders in England and Wales. The Board will meet three times a year to advise the NPSA on medication safety risks and propose actions to minimise them. The Board will provide a formal structure to any collaborative work to ensure that medication safety remains a top priority in NHS funded care. The Board will meet for the first time in October; for more information contact the NPSA Press Office.


The NPSA has a number of tools and resources available to support organisations to understand and to make changes to their working practices and safety culture with the aim of reducing harm to patients.


These tools include:

Seven steps to patient safety – a best practice guide to key areas of activity to ensure patient safety is being addressed in an individual organisation.


The Manchester Patient Safety Framework (MaPSaF) – a tool that helps organisations measure their progress towards making patient safety a central focus within an organisation.


Being open – the NPSA’s Being Open policy and tools help healthcare staff communicate honestly and sympathetically with patients and their families when things go wrong.


Root cause analysis (RCA) – the RCA toolkit provides a framework for reviewing patient safety incidents. Investigations can identify what, how, and why patient safety incidents have happened. Analysis can then be used to identify areas for change, develop recommendations and look for new solutions.


Incident Decision Tree (IDT) – the IDT tool has been created to complement the NPSA’s RCA toolkit and to help NHS managers and senior clinicians to use a fair and just process to assess the intentions of staff involved in a serious patient safety incident and to identify appropriate management action. 


Foresight Training – this resource pack has been developed to improve awareness in nursing and midwifery of the factors that combine to increase the likelihood of patient safety incidents. The pack contains a range of training scenarios, paper and video-based and supporting materials for use by a facilitator.

The National Patient Safety Agency is an Arm’s Length Body of the Department of Health. It encompasses three divisions; the National Research Ethics Service, the National Reporting and Learning Service and the National Clinical Assessment Service. Each has its own sphere of expertise to improve patient outcomes. The NPSA’s vision is to lead and contribute to improved, safe patient care by informing, supporting and influencing healthcare individuals and organisations.