I have stated before in the columns of this journal that medicines management is all about risk management. These risks may be financial or clinical. All too often in cash-limited healthcare systems the focus is on the financial risks associated with medicines. Therefore, it is refreshing to see a number of articles in this edition of Hospital Pharmacy Europe which are focused on reducing the clinical risks associated with injectable medicines. These articles approach the safety issue from different angles.
The article by Valia Humbert-Delaloye and colleagues describes the initiative in her own hospital to improve safety by improving the provision of information around incompatibilities of IV medications administered through the same line. The initiative takes a pragmatic approach to improving safety, recognising that it is often not practical to administer IV medication through separate lines in the critical care environment, and adopts a strategy of improving information at the point of use.
A different approach to improving safety with IV medication is described in the article by Frank Ellwood. He discusses the issues surrounding the use of prefilled syringes of contrast media during computerised tomography scanning. The strategy advocated in this article attempts to eliminate the cause of the risk and could be described as “purchasing for safety”. The meeting report on the roundtable organised by HPE on this topic also considers the use of prefilled syringes in radiology to improve safety, but this time in the context of the wider safety issues associated with all injectable medicines, which is the focus of the latest patient safety alert issued by the National Patient Safety Agency (NPSA) in the UK.
The NPSA collects information on incidents from healthcare organisations and uses this data to identify common problems, and through the production of patient safety alerts recommends actions to minimise these problems. This is based on the principle of learning from mistakes, which for healthcare organisations in the UK has been described as creating “an organisation with a memory”. The NPSA has found that 24% of all medication-related incidents reported involved injectable medicines. Although the vast majority of these incidents caused no harm, over an 18-month period 25 incidents resulted in death and 28 in serious harm. The NPSA has previously issued patient safety alerts related to specific injectable medicines. However, as a result of these findings, the NPSA has issued a patient safety alert on all injectable medicines, which �recommends a number of actions for UK NHS organisations. However, the actions recommended in the NPSA alert are generic enough to be applicable to any country and any healthcare setting where injectable medicines are administered. A key recommendation is for a risk assessment of all injectable medicines to be carried out in the clinical areas in which they are used. To support this, the NPSA has developed a risk assessment tool, which can be found on the NPSA website (see Resource) in addition to this and other medicines-related patient safety alerts.
A number of strategies are identified in this latest safety alert, including purchasing for safety, training and the provision of information at the point of use, all of which are discussed in the articles in this edition of HPE. The NPSA alert puts the pharmacist at the centre of the risk assessment process, working with other healthcare professionals in the relevant clinical area. This is right and proper, as pharmacists are at the centre of the medicines management agenda in hospitals.
It is all too easy for us as hospital pharmacists to focus on clinical issues in relation to prescribing and on pharmaceutical issues in relation to the medicines supply chain, and ignore the risks associated with the preparation and administration of injectable medicines in clinical areas. I am reminded of RL Wolsey’s quote in the Journal of The American Medical Association: “Society has invested in developing wondrous new pharmacological therapies, but has failed to invest adequately in their safe use.”
Resource
National Patient Safety Agency
Author
Ray Fitzpatrick
Consultant Editor
