Drug dispensing errors in NHS cause hundreds of deaths


Drug dispensing errors in the NHS are causing hundreds of deaths every year, according to researchers from the Universities of Sheffield, York and Manchester.

Their study, which revealed an estimated 237 million drug errors occur in the NHS in England every year, and avoidable adverse drug reactions (ADRs) cause hundreds of deaths, prompted health and social care minister Jeremy Hunt to call for the creation of a culture where checks are put in place to stop errors from happening.

Researchers from the Universities of Sheffield, York and Manchester report that an estimated 712 per year deaths result from avoidable ADRs. Their report reflects on 36 studies that detail drug error rates in primary care, care homes and secondary care.

ADRs could be a contributory factor to between 1,700 and 22,303 deaths a year, according to the researchers.

Of the total estimated 237 million drug errors that occur, researchers found that almost three in four are unlikely to result in harm to patients, but there is very little information on the harm that actually happens due to drug errors.

This led researchers to review studies related to the harm caused to patients from ADRs. As well as the number of deaths reported, they also showed that avoidable ADRs had significant cost implications, at £98.5 million per year, but this could be significantly higher.

The economic impact of drug errors varied widely, from £60 per error for inhaler drugs, for example, to more than £6 million in litigation claims associated with anaesthetic errors.

The team is calling for more work to be done on finding cost-effective ways of preventing drug errors and their potential harm to patients.

Fiona Campbell, research fellow at the University of Sheffield’s School of Health and Related Research, said: “Measuring harm to patients from medication errors is difficult for several reasons, one being that harm can sometimes occur, when medicines are used correctly, but now that we have more understanding of the number of errors that occur we have an opportunity to do more to improve NHS systems.”

Professor of health economics at the University of York, Mark Sculpher, said: “Although these error rates may look high, there is no evidence suggesting they differ markedly from those in other high-income countries.”

“Almost three in four errors would never harm patients and some may be picked up before they reach the patients, but more research is needed to understand just how many that is.”

‘Culture of checks’

Hunt told BBC News during an interview on the research that “we are seeing four to five deaths every single day because of errors in prescription, dispensing or the monitoring of medications”.

He said: “It’s very important to say this is not about blaming doctors, nurses or pharmacists who work incredibly hard under a huge amount of pressure, but it is about having a culture where we have the checks in place to stop this happening and where we’re able to learn from mistakes.”

Hunt added that a new law is being introduced that will see pharmacists avoid prosecution if they own up to mistakes.

Dr Pallavi Bradshaw, senior medicolegal adviser at the Medical Protection Society, said: “Medication errors account for a considerable number of complaints, claims and patient safety incidents and the Government’s desire to tackle the issue is welcomed.

“It is important to note however that many errors are down to human error rather than a lack of knowledge; for example accidently prescribing the wrong medication, administering an incorrect dose, an oversight regarding allergies or a mix up in patients. These unfortunate and unintended mistakes occur at various points in the process and involve different healthcare professionals.”

Bradshaw welcomed the new defences for pharmacists who make accidental medication errors as a “step in the right direction”.

Bradshaw added: “But to bring about a real shift towards a culture of openness, learning and improvement from system wide mistakes, these defences would need to be extended to doctors and other healthcare professionals. There has never been a more important time to debate this issue, and we are pleased work is underway.”

The government is forming an expert group to work on introducing a new cap on the amount of costs that lawyers can recover in clinical negligence cases.

Fixed recoverable costs for clinical negligence claims were hanging in consultation limbo and believed unlikely to come in effect until 2019 at the earliest, but the government’s response was published on 15 February.


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Mark Dugdale is the editor of Claims Media. Mark welcomes articles, letters or feedback from readers and can be reached via mark.dugdale@barkerbrooks.co.uk