teaser
Lisa Smith
BPharm(Hons) MSc
Medicines Governance Pharmacist
Ulster Hospital Belfast
UK
E:[email protected]
Medication incidents have been identified as a major cause of preventable patient injury and have been estimated to occur in 2–15% of patients admitted to hospital.(1,2) Medication incidents account for 20% of all clinical negligence litigation and have been estimated to cost the NHS £500m per annum (= e. 702m) in additional days spent in hospital.(3,4)
Within the UK, the Department of Health has set a target for hospitals to reduce the number of serious errors in the use of prescribed medicines by 40% by 2005.(3) To address medication safety issues and reach government targets it is necessary to have a successful medication incident reporting system as a means of identifying areas of risk.
The Department of Health, Social Services and Public Safety in Northern Ireland has funded a two-year medicines governance project, which commenced in August 2002 within secondary care. The author is one of a team of six hospital-based pharmacists who aim to improve patient safety with respect to medicines.
The Ulster and Community Hospitals Trust provides acute hospital services and community health and social services. During 2001/2002, incident reporting was reviewed and rationalised within the trust. This rationalisation resulted in a trustwide policy for the reporting of incidents and the development of two incident reporting forms. Medication incidents are reported on one form, and all other clinical and nonclinical incidents are reported on the other.
This article describes how the medication incident report form was developed and how the incident reporting process operates in practice.
Development of the medication incident reporting form
A draft reporting form was prepared by the pharmacy team and approved by the multidisciplinary drug and therapeutics committee within the trust. This form was designed to be simple and quick to complete, confidential and anonymous; it would facilitate collection of all the relevant information required to analyse medication incidents and identify trends. The issue of anonymity is contentious and was discussed at length throughout the trust. In the interest of increasing reporting, to ensure patient safety, and based on the results of staff consultation, it was decided to allow reporter anonymity on the medication incident reporting form but to ensure the relevant patient details were recorded. The draft form was piloted within three directorates during March to May 2001. During the pilot, 344 reports were submitted. A questionnaire was conducted to assess staff opinion of the ease of use of the draft form. This in combination with a review of the submitted forms led to the development of a revised Med-i-form (see Figure 1). This consists of a single A4 form, with instructions for completion on the reverse of the form. These forms are readily available on all wards and departments. Stocks are maintained by the pharmacy technicians via the pharmacy “top-up service”. Ward staff are encouraged to store the forms in easily accessible positions on the ward such as on the medicine trolley. The Med-i-form was launched within the trust in June 2002.
[[HPE09_fig1_40]]
Incident management
Completed forms are sent to the pharmacy for analysis and coding. Each incident is coded according to its severity and potential impact, using the guidance in the Department of Health publication Doing less harm.(5)
To facilitate identification and analysis of trends, each incident is coded according to its description – prescribing, dispensing, administration or transcribing. A further code from a list of 66 is assigned that describes the incident type. Examples include: illegible prescription, duplication of therapy, incorrect patient and omission of intended therapy on admission. Information from each Med-i-form is stored and can be easily retrieved on a Microsoft Access database.
Feedback
Each month, a summary of the submitted reports is prepared. This includes the total number of reports, details of incidents that caused patient harm, and those incidents that have had the potential to cause severe or fatal consequences. This summary is sent to lead medical and nursing personnel within each directorate and the pharmacy team for review and dissemination. In addition, each directorate receives details of incidents occurring within their directorate. Periodically, trends are identified: for example, problems with a particular drug or high incidence of a specific type of incident. This ensures that information is shared and helps facilitate trustwide learning.
Changes implemented
The medication incident reporting system is designed to focus on systems. Many changes to improve medication safety have already been identified and changes introduced. Some examples are described in Table 1. Changes in drug policy are introduced through consultation with appropriate users and approved via the drug and therapeutics committee.
[[HPE09_table1_40]]
Future developments
The medication incident reporting system has been in operation since June 2002. The number of reports submitted each month continues to rise as staff become more familiar with the system and aware of the positive impact reporting has on patient safety. The majority of reports are submitted by pharmacists as shown in Figure 2. It is hoped that continued promotion and feedback will further encourage reporting, particularly among the medical and nursing professions.
[[HPE09_fig2_41]]
Acknowledgements
I wish to acknowledge the hard work and commitment of Shirley McKenna, who was responsible for the pilot and for introducing the changes, which resulted in the Med-i-form. I also wish to acknowledge the support and participation of pharmacy, nursing and medical staff throughout the trust and the advice and support offered by the risk management department.
References
- Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse drug events: implications for prevention. JAMA 1995;274:29-34.
- Leape LL. Error in medicine. JAMA 1994;272:1851-7.
- Department of Health. An organisation with a memory. Report of an expert group on learning from adverse events in the NHS. London: The Stationery Office; 2000.
- Department of Health. Building a safer NHS for patients. London: The Stationery Office; 2001.
- Department of Health. National Patient Safety Agency. Doing less harm. London: The Stationery Office; 2001.
