A pregnant woman who died after receiving the wrong dose of medication was one of nearly 6,000 people harmed and 29 killed following prescription errors on the NHS in England last year.
figures of National Health Service England shows that 98 hospital trusts saw an increase in the number of prescription errors reported in 2021, including cases where patients were given the wrong medicine, the wrong dose or the medicine was not given when needed. Meanwhile, the number of errors fell to 105 trusts.
The Leeds Community Health Care Trust saw a sixfold increase in prescription errors, with 111 errors, up from just 17 in 2020. At the Royal National Orthopedic hospital, errors rose from 60 to 193, while the Trust Herefordshire Association College NHS had 55 errors, up from 20 in 2020.
The NHS said almost one in six trusts did not yet have a fully funded plan to introduce ePrescriptions, meaning they are still run, at least partially, on paper notes.
Peter Walsh, executive director of Action Against Medical Accidents, said: “These are very disappointing statistics and behind each one there is a story of personal suffering or tragedy. What’s particularly frustrating is that prescribing errors are probably easier to prevent than many things that go wrong in health care.
“The fact that almost one in six trusts do not have a funded plan to reduce these errors is quite shocking. Even with those who do, having a plan is not enough.
“We are especially concerned about vulnerable people, such as the elderly or disabled people in nursing homes, who may be more at risk because they may have less ability to manage themselves and because they tend to receive less personalized service than the average patient.” .
The vast majority of prescribing incidents (86%) were recorded as not causing patient harm, and overall the number of prescribing errors recorded in the National Reporting and Learning System (NRLS) decreased from 44,928 in 2020 to 43,452 in 2021.
However, 5,349 were recorded as causing a low level of damage, meaning they required additional observation or minor treatment. Another 520 incidents caused a moderate degree of harm, which may lead to additional treatment, possible surgical intervention, cancellation of treatment, or transfer to another area.
There were 49 incidents that caused serious harm, while in 29 cases incidents that resulted in the death of patients were recorded.
In one case, a patient was seen in the anticoagulant clinic. She informed them that she was pregnant, which means her blood clot medication Warfarin was discontinued (it is considered unsafe during pregnancy). A series of miscommunications meant that the patient was instead prescribed twice as much Dalteparin as she should have been, and then she died of a brain haemorrhage. The incident only came to light 10 months later when the coroner requested a report from the doctor.
NHS England said that while the NRLS aims to record the actual degree of harm suffered by the patient, the sheer number of organizations reporting to the system means cases were not always accurately coded.
The NHS is undergoing a transition to a new system for recording patient safety incidents.
An NHS spokesman said: “Patient safety is paramount, and although they are rare in the context of the millions of patients who receive hospital care each year, it is vital that any prescription errors are reported quickly and steps are taken to prevent future errors. mistakes.
“As part of this action, over the last three years, the NHS has invested £75m in electronic prescribing systems, which can reduce prescription errors by almost a third, and more than five in six trusts now have a fully funded plan to introduce electronics. prescribing.”
Steph Lawrence, Executive Director of Nursing and Allied Health Professionals at Leeds Community Healthcare, said: “The NHS Trust in Leeds Community Healthcare recognizes that a good safety culture is based on incidents that are reported to staff by staff. as they occur. We are proud of the safety culture within the organization.
“Thirty-seven percent of all medication-related incidents reported by LCH staff occur in some other part of the health and social care system. Our staff play a key role at the care interfaces between hospitals and GPs, identifying and resolving issues that may include prescription drug issues, and this is reflected in the numbers reported to NRLS.”